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 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
Components ofNutritional 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
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
What to Measure?
Anthropometry Laboratory tests Clinical assessments Diet 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 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])
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
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
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 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
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
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 parameter
s
Energy intake?
OK NONormal
LOW YES Abnormal
Source: Adapted from Hellerstein and Kotler 1998
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
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 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)
Consider
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)
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 Regimensfor HIV-Related Weight
LossTherapy 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
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
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)
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
IncreaseVitamin 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 bloating
Iron: 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 vomitingSource: Afacan et al 2002, Tang et al 1996; Ziegler and Filler
1996
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
Follow up and Review
Monitor the Client’s 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
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 Hyperglycemia, insulin resistance, and glucose intolerance Peripheral wasting (extremities, face) 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 Antioxidants (e.g., vitamin C and selenium) to
support glutathione, which is crucial in insulin action
Hyperglycemiaand 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 Decreased fat intake Exercise 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 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
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