HIV/AIDS AND NUTRITION: An Update On Current Knowledge

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Key Nutrition Actions for People Living with
HIV/AIDS



Nutrition and HIV/AIDS A Training Manual Session
3

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Purpose

• To provide general nutrition and dietary
  guidelines to mitigate the effects of HIV on
  nutrition and reduce the progression of HIV/AIDS
  morbidity, mortality, and related discomfort

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Session Outline

• Goals of nutrition care and support in HIV/AIDS
• Essential components of nutrition care and
  support in HIV/AIDS
• Key actions for HIV-infected people
• Appropriate assessments, interventions, follow-up
  and review for nutritional care in HIV/AIDS

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Goals ofNutrition Care and Support

• Improve nutritional status
• Maintain weight and prevent weight loss
• Preserve muscle mass
• Ensure adequate nutrient intake
• Improve eating habits and diet
• Replenish stores of essential nutrients
• Prevent food-borne illnesses
• Enhance quality of life
• Treat opportunistic infections
• Manage symptoms affecting food intake
• Provide palliative care

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Components ofNutritional Care and Support

• Nutritional assessment
• Intervention
• Follow up and review

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Nutritional Assessment
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Why Measure?

• To identify and track body composition changes
  over time and trends
• Changes in weight
• Changes in body cell mass and fat-free mass
• Serum nutrient levels, cholesterol, etc.
• To use results to design appropriate
  interventions
• To address client concerns about their health
• To meet increasing emphasis on physical nutrition
  assessment as part of clinical trials

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What to Measure?

• Anthropometry
• Laboratory tests
• Clinical assessments
• Diet history and lifestyle

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Anthropometric Measurementsin HIV/AIDS

• To assess and monitor weight
• Weight and height
• Percentage of weight and/or body mass index
  changes over time
• To assess and monitor body composition
• Lean body mass
• Body cell mass
• Skinfold (triceps, biceps, mid-thigh)
• Circumferences (waist, mid-upper arm, hips
  buttocks, mid-thigh, breast size for women,
  neck circumferencve (buffalo hump)

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Laboratory Measurementsin HIV/AIDS

• To assess and monitor nutrient levels
• Serum micronutrients (e.g. retinol, zinc)
• Haemoglobin (and ferritin)
• To assess and monitor body composition
• Fasting blood sugar,
• Lipid profiles (e.g., cholesterol and
  triglycerides)
• Serum insulin

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Clinical Assessments in HIV/AIDS

• Symptoms and illnesses associated
• with HIV/AIDS
• Diarrhea and vomiting
• Fever (temperature)
• Mouth and throat sores
• Oral thrush
• Muscle wasting
• Fatigue and lethargy
• Skin rashes
• Edema
• Palm pallor

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Diet History in HIV/AIDS

• 24-hour food consumption or food
• frequency recalls can be used (in the
• absence of acute food stress) to assess
• Types and amounts of food eaten (including food
  access and utilization and food handling)
• Use of supplements and medications
• Factors affecting food intake (appetite, eating
  patterns, medication side effects, lifestyle,
  taboos, hygiene, psychological factors, stigma,
  economic factors)

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Interventions
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Stages of HIV Disease and Nutrition

• Specific nutrition recommendations vary
• according to underlying nutritional
• status and HIV disease progression
• Early stage No symptoms, stable weight
• Middle stage Weight loss, opportunistic
  infections associated effects
• Late stage Symptomatic AIDS

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Nutrition Care and Support Priorities by Stage of
Disease

• Asymptomatic Counsel to stay healthy
• Encourage building stores of essential nutrients
  and maintaining weight and lean body mass
• Ensure understanding of food and water safety
• Encourage physical activity
• Middle stage Counsel to minimize consequences
• Counsel to maintain dietary intake during acute
  illness
• Advise increased nutrient intake to recover and
  gain weight
• Encourage continued physical activity
• Late stage Provide comfort
• Advise on treating opportunistic infections
• Counsel to modify diet according to symptoms
• Encourage eating and physical activity

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Nutrition Actions for HIV-Infected People

• To prevent weight loss
• Promote adequate energy and protein intake
• Individualize meal plan and modify to match
  medication regime or health changes
• Advise changing lifestyles that negatively affect
  energy and nutrient intake
• To improve body composition
• Promote regular exercise to preserve muscle mass
• Promote steroids
• To improve immunity and prevent infections
• Promote increased vitamin and mineral intake
• Promote food safety
• Promote use of ARVs to reduce viral load

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Algorithm for Managing Weight Loss in Patients
with HIV/AIDS
Source Adapted from Hellerstein and Kotler 1998
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Promote AdequateNutrient Intake

• Identify locally available and acceptable foods
• Promote a diet adequate in energy, protein and
  other essential nutrients
• Increase energy intake by 10-15
• Increase protein intake
• Increase eating a variety of foods (especially
  more fruits and vegetables) and/or promote
  multiple micronutrient supplements for improved
  immune function

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Support Individualized Meal Plans

• Consider
• Stage of illness and symptoms
• Food security (availability and accessibility of
  basic foods)
• Resources (money, time, other caretakers)
• Food likes and dislikes
• Knowledge, attitudes, and practices (especially
  traditional dietary taboos)

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Modify Meal Plans to Suit Medication and Health
Status
Consider

• Flexibility to change depending on client context
• Possible food and drug interactions
• Changes in medication regimens
• Absence of opportunistic infections and other
  infections that may affect food intake or
  utilization
• Changes in food accessibility in terms of quality
  and quantity (especially in resource-poor
  settings)

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Promote Lifestyle Changes for Nutritional
Well-being

• Eliminate foods and practices that aggravate
• infection
• Raw eggs and unpasteurized dairy products
• Foods not thoroughly cooked, especially meats
• Unboiled water or juices made from unboiled water
  
• Avoid foods that may affect food intake
• Alcohol and coffee
• Junk foods with little nutritional value
• Foods that aggravate symptoms related to
  diarrhea, nausea and vomiting, bloating, loss of
  appetite, and mouth sores (e.g., expired foods,
  fatty foods)

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Recommend Regular Exercise

• Muscle loss can be restored by reducing
• viral load or maintaining physical activity
• Physical activity improves
• Lean body mass
• Body composition
• Bone density
• Strength
• Functional capacity
• Quality of life
• Appetite

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Therapeutic Regimensfor HIV-Related Weight Loss
Therapy Nitrogen retention (g/day) Rate of change in body composition Rate of change in body composition
Therapy Nitrogen retention (g/day) LBM (kg/wk) Weight (kg/wk)
Megestrol acetate NA 0.00-0.05 0.45
Parental nutrition NA 0.00 0.30
rGH 4.0 0.25 0.13
Nandrolone (hypogonadal) 3.7 0.25 0.41
Resistance exercise alone 3.8 0.48 0.53
Resistance exercise and oxandrolone 5.6 0.86 0.84
Source Adapted from Hellerstein and Kotler 1998
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ExercisesThat Build Muscle Mass

• Weight bearing exercises
• Resistance training
• Weight training
• Exercises generating high force on bone
• Aerobics
• Jogging
• Stair climbing
• Hiking
• Skipping
• Relaxation exercises
• Yoga

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IncreaseVitamin and Mineral Intake

• Strategies to increase vitamin and mineral intake
  to
• replenish or build body stores and optimize
  immune
• function
• Food-based approaches
• Include local vegetables, vitamin-enriched or
  fortified local products (maize meal, wheat or
  soy flour, margarine, cereals)
• Have no undesirable side effects
• Are affordable
• Nutrient supplements
• Are more absorbable by sick person
• Multivitamin and multiple-micronutrient
  supplements are better than than single vitamins
  and minerals

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Suggested Nutrient Supplement Intake in HIV/AIDS
Vitamin A RDA5,000 IU) 2-4 RDA (13,000-20,000IU)
Vitamin E 400-800 IU
Vitamin B High-potency B complex (e.g., B-25 or B-50 with niacin and B6)
Vitamin C 1,500-2,000mg
Selenium 200mcg
Zinc 1 RDA (12-19mg)
Source Serono 1999 Tang et al 1996. Excerpts
from Eat up
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Adverse Effects of Too Much Intake of Nutrient
Supplements

• Vitamin E Malabsorption of vitamins A and K and
• gastrointestinal upsets
• Vitamin C Gastrointestinal upsets, iron
  overabsorption
• and abdominal bloating
• Iron Gastrointestinal bleeding (manifested by
  vomiting and
• bloody diarrhea) and possible stimulation of
  viral replication
• Zinc Gastric distress, nausea, reduced immune
• function that favors viral replication (HDL
  reported in
• supplements of gt 300mg/day)
• Vitamin B Gastrointestinal upsets
• Selenium Skin lesions, nausea, and vomiting

Source Afacan et al 2002, Tang et al 1996
Ziegler and Filler 1996
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Promote Food Safetyto Prevent Food-Borne Illness

• Educate clients to avoid products that
• Contain raw or undercooked meat
• Have expired
• Are in damaged or bulging packing
• Are displayed unsafely (e.g., mixing raw and
  cooked foods or meats with fruits and vegetables)
• Are sold in unsanitary conditions or by workers
  with poor personal hygiene or food handling
  practices

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Follow up and Review
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Monitor the Clients Well-being

• Follow up
• Integrate with other care and support activities
  where available
• Do continuously in facility and home
• Include monitoring of health, nutrition, and
  dietary indicators
• Include counseling to address barriers to good
  nutrition
• Offer support and encouragement
• Review
• Meal plans
• Exercise regimens
• Use of medicines
• Compliance with meal requirements

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Factors to Consider in Care and Support of
People Living with HIV/AIDS
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Factors in Design and Implementation

• Social Support, stigma, gender roles, education,
  information, traditions, beliefs
• Economic Household resources, food security,
  financial access to health and nutrition
• Client rights Privacy, nondiscrimination in
  public services
• Quality of support and care Counseling,
  infrastructure, consistency, access to VCT and
  ARVs, information on ARVs

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Nutritional and Antiretroviral Therapy
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Common Antiretroviral Drugs

• Reverse transcriptase inhibitors (RTIs)
• Nucleoside reverse transcriptase inhibitors, or
  NRTIs Zidovudine (AZT,ZDV), Lamivudine (3TC),
  Abacavir (ABC)
• Non-nucleoside reverse transcriptase inhibitors,
  or NNRTIs Nevirapine (NVP), Efavirenz (EFV),
  Delavirdine (DLV)
• Protease inhibitors (PIs)
• Saquinavir (SQV)
• Ritonavir (RTV)
• Indinavir (IDV)
• Often taken in combination to increase
  effectiveness
• and reduce resistance

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Promote Use of ARVs

• Reduces viral load, associated opportunistic
  infections, and immunity to other infections
• Reduces HIV-related wasting and the negative
  effects on body composition
• Reduces deficiencies of micronutrients such as
  zinc and selenium (Rousseau et al 2000)

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Educate on Nutrition-Related Side Effects of ARVs

• Lipodystrophy (fat maldistribution)
• Hyperglycemia/insulin resistance
• Hyperlipidemia

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Lipodystrophy

• Means fat maldistribution
• Is observed in 6-80 of patients on ARVs
• Is caused by metabolic changes associated with
  immune reconstitution and ARV mitochondrial
  toxicity
• Results in
• Hyperlipidemia
• Hyperglycemia, insulin resistance, and glucose
  intolerance
• Peripheral wasting (extremities, face)
• Visceral and subcutaneous central adiposity
  (buffalo hump, breast enlargement)
• Managed by exercise training

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Hyperglycemiaand Insulin Resistance

• Hyperglycemia Increased blood sugar levels from
  pancreatic problems or insulin resistance
• Insulin resistance (impaired message system)
  reported in 28-35 of adult patients on ARVs
• Few cases of diabetes (3-9)
• Management with
• Antidiabetic agents
• Antioxidants (e.g., vitamin C and selenium) to
  support glutathione, which is crucial in insulin
  action

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Hyperlipidemia

• Changes triglycerides or cholesterol with or
  without fat maldistribution
• Is caused by ARV interference with normal
  cellular proteins involved with lipid metabolism
• Increases levels of triglycerides or cholesterol
  and risk of cardiovascular problems and
  pancreatitis
• Is managed by
• Lipid-lowering drugs
• Decreased fat intake
• Exercise
• Lifestyle changes (e.g., quitting smoking)

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Nutritional Care and Support Strategies with ARV
Therapy

• Promote a nutritionally adequate diet (quality,
  diversity, and quantity)
• Promote safe water, food, and hygiene practices
• Discourage excessive fat intake (promote modest
  fats, starches, and sugars and high-protein food
  but fewer fried eggs and yolks), fatty meats, and
  animal fats
• Prevent muscle wasting with regular exercise to
  burn fat and build muscle mass (anabolic agents?)
• Encourage increased fluid intake
• Address nutritional consequences of drug-nutrient
  interactions and side effects of medications

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Conclusions

• Good nutrition and healthy lifestyle can preserve
  health, improve quality of life, prolong
  independence, and delay disease progression
• Appropriate physical activity, increases energy,
  stimulates appetite, and preserves and builds
  lean body mass
• Preventing food- and water-borne infections
  reduces the risk of diarrhea (a common cause of
  weight loss), malnutrition, and HIV disease
  progression
• Antiretroviral therapy can help improve quality
  of life, but patients should be educated on
  adverse nutrition-related effects