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