Nutrition and HIV/AIDS: A Training Manual Session 3
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
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
Goals of Nutrition Care and Support • Improve nutritional status
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Maintain weight and prevent weight loss−
Preserve muscle mass
• Ensure adequate nutrient intake−
Improve eating habits and diet
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Replenish stores of essential nutrients
• Prevent food-borne illnesses
• Enhance quality of life−
Treat opportunistic infections
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Manage symptoms affecting food intake
• Provide palliative care
Components of Nutritional Care and Support
1. Nutritional assessment
2. Intervention
3. Follow up and review
Nutritional Assessment
Why Measure?To identify and track body composition changes over time and trends−
Changes in weight
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Changes in body cell mass and fat-free mass
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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
What to Measure?
AnthropometryLaboratory testsClinical assessmentsDiet history and lifestyle
Anthropometric Measurements in 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 compositionLean body massBody cell massSkinfold (triceps, biceps, mid-thigh)Circumferences (waist, mid-upper arm, hips [buttocks], mid-thigh, breast size for women, neck circumferencve (buffalo hump])
Laboratory Measurements in HIV/AIDS
To assess and monitor nutrient levels Serum micronutrients (e.g. retinol, zinc)Haemoglobin (and ferritin)
To assess and monitor body compositionFasting blood sugar,Lipid profiles (e.g., cholesterol and triglycerides)Serum insulin
Clinical Assessments in HIV/AIDSSymptoms and illnesses associated with HIV/AIDS
Diarrhea and vomitingFever (temperature)Mouth and throat soresOral thrushMuscle wastingFatigue and lethargySkin rashesEdemaPalm pallor
Diet History in HIV/AIDS
24-hour food consumption or foodfrequency recalls can be used (in theabsence 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)
Interventions
Stages of HIV Disease and Nutrition
Specific nutrition recommendations varyaccording to underlying nutritionalstatus and HIV disease progression
Early stage: No symptoms, stable weight
Middle stage: Weight loss, opportunistic infections associated effects
Late stage: Symptomatic AIDS
Nutrition Care and Support Priorities by Stage of Disease
Asymptomatic: Counsel to stay healthyEncourage building stores of essential nutrients and maintaining weight and lean body massEnsure understanding of food and water safetyEncourage physical activity
Middle stage – Counsel to minimize consequencesCounsel to maintain dietary intake during acute illness Advise increased nutrient intake to recover and gain weightEncourage continued physical activity
Late stage: Provide comfortAdvise on treating opportunistic infectionsCounsel to modify diet according to symptomsEncourage eating and physical activity
Nutrition Actions for HIV- Infected People
To prevent weight lossPromote adequate energy and protein intakeIndividualize meal plan and modify to match medication regime or health changes Advise changing lifestyles that negatively affect energy and nutrient intake
To improve body compositionPromote regular exercise to preserve muscle massPromote steroids
To improve immunity and prevent infectionsPromote increased vitamin and mineral intakePromote food safetyPromote use of ARVs to reduce viral load
Algorithm for Managing Weight Loss in Patients with HIV/AIDS
DX Profile=starved metabolism, decreased
body fat/lean
RX=Feed (IV, enteral, appetite stimulation), make meal plans, promote positive lifestyles, treat symptoms that may affect food intake
DX Profile=starved metabolism, decreased
body fat/lean
RX= Treat GI disorders and other infections, consider supplements and drug-food interactions, counsel on hygiene and food handling
DX Profile=abnormal metabolism, relatively high fat/lean ratio; low
testosterone.
RX=Make an exercise plan, provide metabolic steroids (?) and ARVs (?)
Etiology unknown or unclear
RX=Continue to feed and observe
Diarrhea or mal- absorption?
Metabolic parameters
Energy intake?
OK NONormal
LOW YES Abnormal
Source: Adapted from Hellerstein and Kotler 1998
Promote Adequate Nutrient Intake
Identify locally available and acceptable foods
Promote a diet adequate in energy, protein and other essential nutrients
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Increase energy intake by 10%-15%
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Increase protein intake
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Increase eating a variety of foods (especially more fruits and vegetables) and/or promote multiple micronutrient supplements for improved immune function
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)
Modify Meal Plans to Suit Medication and Health Status
Flexibility to change depending on client contextPossible food and drug interactionsChanges in medication regimensAbsence of opportunistic infections and other infections that may affect food intake or utilizationChanges in food accessibility in terms of quality and quantity (especially in resource-poor settings)
Consider
Promote Lifestyle Changes for Nutritional Well-being
Eliminate foods and practices that aggravateinfection−
Raw eggs and unpasteurized dairy products
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Foods not thoroughly cooked, especially meats −
Unboiled water or juices made from unboiled water
Avoid foods that may affect food intake−
Alcohol and coffee
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“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)
Recommend Regular Exercise
Muscle loss can be restored by reducingviral load or maintaining physical activity
Physical activity improves• Lean body mass• Body composition• Bone density• Strength• Functional capacity• Quality of life• Appetite
Therapeutic Regimens for HIV-Related Weight Loss
Therapy Nitrogen retention (g/day)
Rate of change in body composition
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
Exercises That Build Muscle Mass
Weight bearing exercises−
Resistance training
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Weight training
Exercises generating high force on bone−
Aerobics
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Jogging−
Stair climbing
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Hiking−
Skipping
Relaxation exercises−
Yoga
Strategies to increase vitamin and mineral intake toreplenish or build body stores and optimize immunefunction
Food-based approaches−
Include local vegetables, vitamin-enriched or fortified local products (maize meal, wheat or soy flour, margarine, cereals)
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Have no undesirable side effects
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Are affordable
Nutrient supplements−
Are more absorbable by sick person
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Multivitamin and multiple-micronutrient supplements are better than than single vitamins and minerals
Increase Vitamin and Mineral Intake
Suggested Nutrient Supplement Intake in HIV/AIDS
Source: Serono 1999; Tang et al 1996. Excerpts from Eat up
Vitamin A RDA=5,000 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)
Adverse Effects of Too Much Intake of Nutrient SupplementsVitamin E: Malabsorption of vitamins A and K andgastrointestinal upsets
Vitamin C: Gastrointestinal upsets, iron overabsorptionand abdominal bloatingIron: Gastrointestinal bleeding (manifested by vomiting andbloody diarrhea) and possible stimulation of viral replication
Zinc: Gastric distress, nausea, reduced immunefunction that favors viral replication (HDL reported in supplements of > 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
Promote Food Safety to 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
Follow up and Review
Monitor the Client’s Well-beingFollow up
Integrate with other care and support activities where availableDo continuously in facility and homeInclude monitoring of health, nutrition, and dietary indicatorsInclude counseling to address barriers to good nutritionOffer support and encouragement
ReviewMeal plans Exercise regimensUse of medicinesCompliance with meal requirements
Factors to Consider in Care and Support of People Living with HIV/AIDS
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
Nutritional and Antiretroviral Therapy
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 effectivenessand reduce resistance
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)
Educate on Nutrition-Related Side Effects of ARVs
Lipodystrophy (fat maldistribution)
Hyperglycemia/insulin resistance
Hyperlipidemia
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
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Hyperglycemia, insulin resistance, and glucose intolerance−
Peripheral wasting (extremities, face)
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Visceral and subcutaneous central adiposity (buffalo hump, breast enlargement)
Managed by exercise training
Lipodystrophy
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
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Antioxidants (e.g., vitamin C and selenium) to support glutathione, which is crucial in insulin action
Hyperglycemia and Insulin Resistance
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
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Decreased fat intake−
Exercise
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Lifestyle changes (e.g., quitting smoking)
Hyperlipidemia
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
Nutritional Care and Support Strategies with ARV Therapy
Conclusions
Good nutrition and healthy lifestyle can preserve health, improve quality of life, prolong independence, and delay disease progressionAppropriate physical activity, increases energy, stimulates appetite, and preserves and builds lean body massPreventing food- and water-borne infections reduces the risk of diarrhea (a common cause of weight loss), malnutrition, and HIV disease progressionAntiretroviral therapy can help improve quality of life, but patients should be educated on adverse nutrition-related effects