HIV Nutrition Essentials For Program and Administrative Grantees

Marcy Fenton, M.S., R.D. Program Manager, Care Services DivisionCounty of Los AngelesDepartment of Public HealthOffice of AIDS Programs and Policy

August 29, 2006

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Los Angeles County

Square Miles: 4,086Population: 9.9 Million

Latino/a 45.7% White 31.0%Asian/PI 13.2%African-American 9.7%Native American 0.3%

Proportion of California Population: 29%

Proportion of California AIDS Cases: 35%

Living with HIV/AIDS:58,000 (Estimated)

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SPA 6: South

SPA 8:South Bay

SPA 5:West

SPA 2:San Fernando

SPA 4:Metro

SPA 3:San Gabriel

SPA 1: Antelope Valley

SPA 7:East

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HIV Nutrition EssentialsOverview

•Current nutrition issues and treatments•Medical nutrition therapy (MNT)

program necessary ingredients •Lessons learned monitoring Los

Angeles County medical outpatient services’ MNT programs

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HIV Nutrition EssentialsHandout Materials

•Presentation slides•Guides and resources

Diet, nutrition, fact sheets Professional competency

•Weight & nutrition •HIV nutrition screen & referral forms

ADA 2005 Nutrition quick screen

Request copies of handouts: MFenton@ladhs.org

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HIV Nutrition Essentials

Current HIV Nutrition Issues

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HIV MNTOverall Goals

•Optimize nutrition status, immunity and quality of life

•Prevent nutrient deficiencies•Achieve and maintain optimal body

weight and composition•Manage co-morbidities•Maximize effectiveness of medications

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Vicious Cycle of Malnutrition and HIV

Poor Nutrition resulting in weight

loss, muscle wasting, weakness, nutrient

deficiencies

Increased Nutritional needs,

Reduced food intake and

increased loss of nutrients

Increased vulnerability to infections e.g.

Enteric infections, flu, TB hence Increased HIV

replication, Hastened disease progression Increased morbidity

Impaired immune system

Poor ability to fight HIV and other

infections, Increased oxidative stress

HIV

Source: Fanta Project www.fantaproject.org Adapted from RCQHC and FANTA 2003

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HIV Nutrition IssuesPoor Immune Function

•Food and water safety, sanitation•Optimized nutrient and fluid intake•Vitamin mineral supplementation•Exercise: aerobic and progressive

resistance training•Medication adherence•Stress reduction •Establishment of trusting relationships

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Nutrition Issues and TreatmentsCommon Side Effects

• GI distress Diarrhea Nausea/vomiting Gas

• Anorexia• Fatigue• Taste alterations• Mouth pain• Anemia

• Hyperlipidemia • Insulin resistance• Hypertension• Liver toxicity• Renal impairment• Obesity• Lipodystrophy• Peripheral neuropathy• Cancer

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Causes of Weight Loss1-Inadequate Intake

•Oral and upper gastrointestinal•Anorexia•Psychosocial-economic•Malabsorption

Source: Mangili A et al. CID 2006:42 (15 March) p 836-42

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Causes of Weight Loss2-Altered Metabolism

•Uncontrolled HIV infection•Metabolic demands of HAART•Opportunistic infections or

malignancies (AIDS-defining conditions)

•Hormonal deficiencies (testosterone or thyroid)

•Cytokine dysregulation

Source: Mangili A et al. CID 2006:42 (15 March) p 836-42

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Resting Energy Expenditure

0

20

40

60

80

100

120

140

CON HIV+ AIDS AIDS-SI

RE

E (K

Joul

es/k

g B

W

Grunfeld et al. AJCN 1992;55:455-60.

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Impact of Viral Load on Resting Energy Expenditure

7900

8100

8300

8500

8700

8900

1 3 5 7 9 11

HIV RNA (log 10 copies/ml)

RE

E (

kjo

ule

s/d

ay)

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HIV WastingDefinitions

•CDC•Nutrition for Healthy Living (Tufts)•Grinspoon, Mulligan & DHHS Working

Group•Polsky, Kotler & Steinhart

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Calories Needed and Weight ChangeRelation to Viral Load

•Not on HAART 0.92 kg body weight decrease per each HIV

RNA log10 increase 22 Kcal increase in REE per increase in per 1-

log copy/ml

• Stable HAART 0.35 kg body weight decrease per each 100-

cell/mm3 CD4 cell decrease 81 kcal higher REESource: Wanke et al. CID 2006:42 (15 March)

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Outcomes of Weight Loss

•Morbidity and mortality independent of CD4 and viral load

•Weight loss of >5% associated with increase risk of mortality even with ART

•Adverse pregnancy outcomes•Weight loss & wasting continue to be

common problems

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International NutritionFeeding Safely and Adequately

• Access to nutritious food • Access to safe water• Malnutrition

Linked with HIV infection Linked with poor prognosis Linked with poor prognosis despite ART

• Breast feeding• Access to HIV medications

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Overweight, Obesity and HIV

05

101520253035404550

Study(n=1669)

NHANESMen

NHANESWomen

BMI <18.5 (1) Wasting (2) Underweight

BMI: 18.5-24.9Healthy Weight

BMI: 25-29.9Overweight

BMI: = or >30Obese

Sources: (1) Amorosa et al. JAIDS 2005;Aug15;39(5):557-61.(2) NHANES 1999-2000; www.cdc.gov 7/03

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Weight Classification Using BMIBMI1 Note

Underweight <18.5 Malnutrition2 <18.5Wasting3 <20.0

Normal 18.5-24.9

Overweight 25.0-29.9

Obesity (I) 30.0-34.9

Obesity (II) 35.9-39.9

Extreme Obesity (III) >40.0

(1) National Heart, Lung and Blood Institute, (2) Magili et al. CID 2006 March, (3) Amorosa; Grinspoon, Mulligan & DHHS Working Group 2003 April-S CID

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Conditions Associated with Obesity

Obesity Hyperlipidemia

Heart Disease

StrokeHypertension

Gout

Non-Insulin Dependent DM

Osteoarthritis

Mood Disorders

Sleep Disorders

Eating Disorders

Some Cancers

Gall Bladder

BMI: HIV vs. General Populations

Contemporary Diagnosis and Management of Obesity. Geroge A. Bray, MD

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Desirable Girth Measurements

• Waist circumference Men: <40 inches Women: <35 inches NHANES methodology

• Waist to Hip Ratio? Less accurate Not recommended Hip circumference ok Monitor waist & hip from baseline

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Overweight, Obesity & HIVFuel of Metabolic Abnormalities

•BMI positive correlation with Total cholesterol Triglycerides Glucose

•Obesity not correlated with Age, income, employment, education Past/current IVD use HIV treatment, viral load

Source: Amorosa et al. JAIDS 2005;Aug15;39(5):557-61.

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Treatment of ObesityTherapeutic Lifestyle Changes

• Nutrition counseling • Dietary intake

Limit saturated fats Increase fiber to 35 g/day Portion control Reduce excess carbohydrates and high

sugar drinks Plenty of fruits and vegetables Small meals: maximum 5 hours apart Eat slowly

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Treatment of ObesityTherapeutic Lifestyle Changes

• Physical activity Walking or other exercise

• 30-60 minutes/day Progressive resistance training

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HIV and Diabetes MellitusAn Increasing HIV Nutrition Problem

• HIV-positive men who are taking highly active antiretroviral therapy (HAART) are more than four times more likely to develop diabetes than HIV-negative men.

• HIV-positive women taking protease inhibitors are three times more likely to develop diabetes than HIV-positive women on non-protease inhibitor combinations or HIV-negative women

Sources: Brown TT et al. Antiretroviral therapy and the prevalence and incidence of diabetes mellitus in the Multicenter AIDS Cohort Study. Arch Intern Med 165: 1179-1184, 2005.

Justman JE et al. Protease inhibitor use and the incidence of diabetes mellitus in a large cohort of HIV-infected women. Journal of Acquired Immune Deficiency Syndromes, 32: 298 – 302, 2003

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Diabetes Major Risk FactorsGeneral Population

• Overweight, obesity Especially VAT

• Parent or sibling • Ethnicity

Alaska Native, American Indian, African American, Latino American, Asian America

• Inactivity Exercise <3x/wk

• History of impaired glucose tolerance or impaired fasting glucose

• Hypertension• Cardio-vascular

disease• Polycystic ovarian

syndrome

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Diabetes Additional Risk FactorsHIV Population

• Medications leading to insulin resistance HAART Steroids, growth hormone, others

• HCV co-infection• Morphological changes

Lipodystrophy: > visceral adipose tissue

• Physical inactivity Neuropathy, fatigue avascular necrosis, wasting,

etc.

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Heart Disease PrevalenceGeneral Population

•Leading cause of death in the U.S.Women: 51% of heart disease deathsMen: 340,933 died from heart disease in

2002•57 million Americans live with CVD

8.9% all white men 7.4% black men 5.6% Mexican American men

1. National Center for Health Statistics. Health, United States, 2005 with Chartbook on Trends in the Health of Americans. Hyatsville, MD: 2005. 2. American Heart Association. Heart Disease and Stroke Statistics—2005 Update. Dallas, Texas: American Heart Association, 2005.

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Heart Disease Major Risk FactorsGeneral Population

• Increasing age• Gender• Heredity, family

history of premature heart disease

• Overweight/obesity• High blood pressure• Tobacco use

• Hyper- or dyslipidemia Especially high LDL

& low HDL• Diabetes• Metabolic syndrome• Physical inactivity• Poor nutrition

An atherogenic dietSource: Preventing chronic diseases: Investing wisely in health preventing heart disease and stroke. July 2005. CDC. February 6, 2006. http://www.cdc.gov/nccdphp/publications/factsheets/Prevention/cvh.htm

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Heart Disease Risk FactorsHIV Population

• Inflammation due to HIV•Lipid abnormalities due to HAART•Other drug effects:

Insulin resistanceMorphological changes Metabolic syndrome

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Heart DiseasePrevention & Treatment

•Therapeutic Lifestyle Change (TLC) Diet Physical exercise

•Management of concomitant diseases Diabetes, hypertension, obesity, etc.

•Smoking cessation•Stress reduction

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Liver DiseaseFueled by Overweight & Obesity

•Waist>hip, insulin resistance & diabetes Predicts advanced forms of chronic

hepatitis CComplicates nonalcoholic steatohepatitis

(NASH)•Fitness inversely related•Tx: Healthy diet, exercise, weight loss

Sources: Charlton MR et al. Hepatology June 2006;46(6)1177-1186; Church TS et al. Gastroenterology. 2006 Jun; 130(7):2023-2030.

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Renal Disease and HIVA Growing Nutrition Problem

•Dialysis HIV: 1.5%, AIDS: 0.4% Dialysis centers treating PLWH/A

• 1985: 11% • 2000: 37%

Number initiated since 1995: stable •Abnormal kidney function

30% PLWH/A •HIV and CKD nutrition guidelines

Not set yet Individualize

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HIV Nutrition Essentials

Medical Nutrition Therapy (MNT)Program Necessary Ingredients

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Continuum of Care

County of Los Angeles. Continuum of Care, Office of AIDS Programs and Policy.

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HIV Registered DietitianStandards of Professional Practice

•Provides quality service based on client expectations and needs

•Effectively applies, participates in or generates research to enhance practice

•Effectively applies knowledge and communicates with others

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HIV Registered DietitianStandards of Professional Practice

•Uses resources effectively and efficiently in practice

•Systematically evaluates the quality and effectiveness of practice and revises practice as needed to incorporate the results of evaluation

•Engages in lifelong self-development to improve knowledge and enhance professional competence

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HIV Registered DietitianCare Responsibility

•Create screening tools for medical providers to identify clients at risk

•Monitor nutrition-related abnormal laboratory values

•Assess clients regularly, consistently•Ensure adequate nutrient & caloric

intake

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HIV Registered DietitianCare Responsibility

•With medical team, identify and correct causes of cachexia, weight loss/gain, other nutrition problems and barriers

•Refer to providers and other disciplines•Communicate: document, speak, share•Participate in team case conferences•Promote continuity of care

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Relationship Between

Patient/Client/Group & Dietetics

Professional

-

Nutrition Diagnosis Identify and label problem Determine cause/contributing risk

factors Cluster signs and symptoms/

defining characteristics

Nutrition Assessment Obtain/collect timely and

appropriate data Analyze/interpret with

evidence - based standards

Identify risk factors Use appropriate tools

and methods Involve

interdisciplinary collaboration

Screening & Referral System

Outcomes Management Sys tem

Monitor the success of the Nutrition Care Process implementation

Evaluate the impact with aggregate data Identify and analyze causes of less than

optimal performance and outcomes Refine the use of the Nutrition Care

Process

ADA NUTRITION CARE PROCESS AND MODEL

Document

Nutrition Monitoring and Evaluation Monitor progress Measure outcome indicators Evaluate outcomes Document

Nutrition Intervention Plan nutrition intervention

Formulate goals and determine a plan of action

Implement the nutrition intervention Care is delivered and actions

are carried out Document

Document

NCP

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Screening and Referral Screen for Referral Criteria

•New/re-entry into care, MNT >6 months•Medical diagnosis, nutrition status

change•Physical changes, weight concerns•Oral, GI symptoms•Metabolic, other medical conditions •Barriers to nutrition, living environment,

functional status•Behavioral concerns, unusual

behaviorsSource: ADA MNT Evidence Based Guides for Practice, March 2005

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Screening and ReferralReferral Documentation

•Physician’s order for MNT •Signature and date of physician or authorized

person to refer for MNT •Medical diagnoses and information•Current labs and measurements•Consent to release medical information•Proof of residency, income, diagnosis

Source: ADA MNT Evidence Based Guides for Practice, March 2005

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Nutrition Care ProcessADIME

•Nutrition Assessment•Nutrition Diagnosis•Nutrition Intervention•Nutrition Monitoring •Nutrition Evaluation

•Documentation: clear and explicit

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Nutrition Care ProcessNutrition Assessment

•Reason for referral•Assess data (ABCD)

AnthropometricBiochemistryClinicalDietary

•Client input

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Nutrition Care ProcessNutrition Diagnosis

• Problem Diagnostic label Intake, clinical, or behavioral/environmental

• Etiology Cause or contributing risk factors

• Signs/Symptoms Defining characteristics

• PES statement

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Nutrition Care ProcessNutrition Diagnosis PES Statement

•(P) Increased nutrient needs (E) as related to inadequate intake of foods and malabsorption due to AIDS enteropathy (S) as evidenced by 25 pound weight loss in 6 months and now 91% IBW

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Nutrition Care ProcessNutrition Intervention

• Interventions Food and/or Nutrient DeliveryNutrition EducationNutrition CounselingCoordination of Nutrition Care

•Receptivity and adherence potential•Plan and follow-up date

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Nutrition Care ProcessNutrition Monitoring

• Review and measure status of intervention at scheduled time

• Track outcomes with tools ADA HIV MNT Protocol Progress Note Weight and nutrition flow sheet Electronic health record data fields

• Format

• Terminology: diagnosis, interventions, etc Other tools

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Nutrition Care ProcessNutrition Evaluation

•Systematic comparisons •Reference standards•Evaluate changes

Signs and symptomsPrevious status and intervention goalsProgress toward goal

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HIV MNT ToolsBasics

• HIV MNT Protocols (ADA,1998) Adult (18 years-adult) Children (under 18 years)

• Health Care and HIV: Nutritional Guide for Providers and Clients (HRSA/HAB, 2002)

• Integrating Nutrition into Medical Management of HIV, (CID-S April 1 2003)

• Nutrition intervention in the care of persons with human immunodeficiency virus. (ADA & Dietitians of Canada Joint Position, 2004)

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HIV MNT ToolsNew: ADA Evidence Analysis Library

Systematic review of scientific research Select topic and expert working group Define questions, analytical framework,

inclusion and exclusion criteria Conduct literature review per question Analyze articles Complete evidence summaries and tables Draft proposed conclusion statements Reach consensus on conclusion statements

and grades (strength and quality of the evidence)

Publish to online library (EAL)

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HIV MNT ToolsNew: ADA EAL Current Projects

•Diseases and conditionsAdult weight managementDeterminants of pediatric overweightChronic kidney disease (revision)Chronic obstructive pulmonary disease Critical illnessDisorders of lipid metabolism

(hyperlipidemia revision)

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HIV MNT ToolsNew: ADA EAL Current Projects

•Diseases and conditions (cont.)Gestational diabetes Gluten intolerance/CeliacHeart failureHIV/AIDSHydrationHypertension

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HIV MNT ToolsNew: ADA EAL Current Projects

•Diseases and conditions (cont.)Nutrition in athletic performanceNutrition care in bariatric surgery OncologyPediatric weight managementSpinal cord injury & nutritionUnintended weight loss

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HIV MNT ToolsNew: ADA EAL Current Projects

•AssessmentEstimating energy expenditure

•Foods Non-nutritive sweetener

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HIV MNT ToolsEmerging: HIV Nutrition Evidence Analysis

• QuestionsWhat are the caloric needs of people with

HIV/AIDS?What is the evidence to support a

particular macronutrient composition of a diet for people with HIV/AIDS? 

•FocusBoth children and adultsPeople with HIV/AIDSPast 10 years of research

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HIV MNT ToolsNew and Emerging

•Nutrition Care Manual Web based Uses ADA Evidence Analysis Library

•Evidence-based MNT protocols•Evidence-based guidelines•ADA position papers

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ReimbursementMNT, Supplements

•Medicare•Medicaid•Managed Care•HMOs, Kaiser Permanente•RWCA

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Personal Professional CompetenceDietetics Professionals’ Ethical Obligation

•Code of Ethics for the Profession of Dietetics,(6)

•Standards of Professional Practice,(7)Guided by the nutrition care process

•Professional Development Portfolio(8) 75 credits every five years

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Ryan White CARE Act and MNTCurrent Status

•MNT by RD Defined by HRSA guidanceRequired in Title III servicesRWCA reauthorization

•Expected after Labor Day 2006•ADA and others working to get MNT as core

medical service

•AIDS Education TrainingHIV nutrition training for providers

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Current Procedural TerminologyMNT CPT Codes

•97802• Initial assessment and intervention, individual,

face-to-face with the patient, each 15 minutes

•97803•Re-assessment and intervention, individual,

fact-to-face with the patient, each 15 minutes

•97804•Group (2 or more individuals), each 30 minutes

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HIV Nutrition Essentials

Lessons Learned MonitoringLos Angeles County

Medical Outpatient Services’ MNT Programs

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Monitoring HIV MNT ServicesMNT Program Evaluation Items

•Screening for nutrition related problems•Referral for baseline MNT (06-07)•Appropriate referral for MNT•MNT provided by an RD•MNT documentation (05-06)•Outcome: maintain or 5% towards goal

weight after 3 months of care (07-08)•RD qualifications

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29 (.8, 0-10)2 (.1, 0-1)Screened

77 (2.1, 0-8)38 (1, 0-4)Referral to MNT

66 (1.8, 0-6)32 (.9, 0-5)MNT Provided

62n/aMNT Quality

244 (6.8, 4-10)

154 (4.3, 2-8)

Charts Reviewed(average, range)

3636Sites (of 37)

16,48716,143Clients (>1 visit)

Yr 15 2005-2006Yr 14 2004-2005

Monitoring MNT Programs

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RD Availability 2004-2005 2005-2006

Clinics, number 37 37

Onsite >½ day/month

28 32

Referral offsite 4 5

None available 5 0

Access to MNT

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Changing Practices and AttitudesEstablishing the Framework for MNT

•Wheels of change move slowly•Develop infrastructure

Standards of care, guidelines, contracts Indicators, monitoring tools, reports

•MNT services: disparity in clinics Providers, program managers, funding Awareness, interpretation and abilities Expectations, goal setting, reporting, access

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Changing Practices and AttitudesTechnical Assistance: Providers and RDs

•Provider meetings, calls, emails •Provider and staff presentations•At each year’s program monitoring

Different and evolving TA focus Always provide materials

Ex: HRSA Nutrition Manual CD, screening & referral forms, articles, standards of care, BMI chart, nutrition & weight flow chart

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Changing Practices and AttitudesTechnical Assistance: RDS

•Dietitians in AIDS Care (DIAC)DIAC listserveQuarterly meetings since April 2005

•Networking – long-lasting relationships

•Training and problem solvingNutrition care process

When to provide/discontinue: nutritional supplements, food / meal services

Hyperlipidemia, insulin resistance, renal disease

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Personal GrowthLessons Learned

•More medical records reviewed•Monitoring tools - streamlined and

tally / comments sheets• Increase time spent monitoring •Evaluation report of MNT programs

Establish ongoing databaseBaseline knowledge of programs

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Screening for Nutrition ProblemsLessons Learned

•Newton’s laws of motion •Providers’ resistance

Problems? Don’t look and you won’t findScreening vs. referringDefining “at risk”

•Make it easy to look, think, document•Simple questions work

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Height and Weight MeasurementsLessons Learned

• Routine measurements needed Height not always measured Weight usually measured Accuracy questionable on both

• Who measures? How trained? Shoes?

• Calibration of scales? Stadiometer?

• Monitoring weight Adding/subtracting usually not done BMI not usually done Graphing not done

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Reducing Barriers to MNT Lessons Learned

•Reducing broken appointmentsSet appointments with clientCoordinate with primary care visitReminders and follow-up calls and letters

•Document in medical record

•Support MNT in clinic Include, discuss and referral from start Incentives and rewards for MNT visitAsk/respond to client request for MNT

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Needed: Proactive Healthy Clinic Lessons Learned

•Take responsibility and power•Educate & support staff: promote:

Nutrition and health knowledgeClients’ food, nutrient and safety needs

•Change the menu and food/ water safety practices for client and non-client eventsMeetings, parties, fund raisers, vending

machines, vouchers, board meetings, holidays, etc.

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HIV Nutrition Essentials

What has been your experience?What has worked well?

What has been a challenge?

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Acknowledgments

Arcy Martinez RDAltaMed Health Services Corporation

Audra Gustafson RDNortheast Valley Health Corporation

Tammy Darke MS RDSt Mary Medical CARE Program

Jill Strejc MS RD SRDUCLA

Caren Ongjoco RD CNSDLos Angeles County Harbor-UCLA Medical Center

Jan B King MD MPHOAPP Medical Director

Marcy Fenton, M.S., R.D.Program Manager, Care Services Division

Office of AIDS Programs and Policy600 South Commonwealth Avenue 2nd Floor

Los Angeles, California 90005-4001Phone: 213/351-8368

Fax: 213/738-6566E-mail: mfenton@ladhs.org

This presentation is available atwww.LAPublicHealth.org/AIDS

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