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Ninuk D.

Learning Objectives
Describe the effect of HIV/AIDS on
Describe the impact of malnutrition on
HIV infection in adults
Identify the effect of micronutrient
supplementation on HIV progression

Learning Objectives
Describe Goals of nutrition care and
support in HIV/AIDS
Describe essential components of nutrition
care and support in HIV/AIDS
Describe key actions for HIV-infected
Describe appropriate assessments,
interventions, follow-up and review for
nutritional care in HIV/AIDS

Learning objective
Describe evidence-based nutritional care

Evidence-based Nutritional

Malnutrition and HIV

Malnutrition and HIV

Malnutrition and HIV are prevalent worldwide
with the highest rates of both in sub-Saharan
Malnutrition influences immune function, the
virulence of infectious agents, progression of
chronic infections such as HIV, and genetic
factors that determine the outcome of sepsis
The association between HIV morbidity and
malnutrition is bi-directional
Malnutrition affects HIV disease progression
HIV affects nutritional status

Types of Malnutrition:
Protein-Energy Malnutrition
Primary PEM caused by inadequate
Secondary PEM is the result of illness,
injuries, or treatments causing altered
appetite, digestion, absorption
Most common form of malnutrition in HIV


Protein-Energy Malnutrition
Used to describe nutritional macrodeficiency
Marasmus: deficiency of calories
Kwashiorkor: deficiency of protein
Nutritional dwarfism in children and wasting syndromes in

Measured as body size by weight or body mass index

[weight (kg) divided by height in (meters)2 ]


< 16: severely malnourished

16-16.9: moderately malnourished
17-18.4: mildly malnourished
18.5-24.9: normal nutritional status

Types of Malnutrition:
Micronutrient Nutrition
Alterations in the stores of fat- and water-soluble
vitamins and trace elements
Clinical symptoms are subtle unless deficiency is
Often accompanies infectious diseases
Most common examples in children and adults:
Iron -> anemia
Vitamin A -> susceptibility to infection, associated with
HIV-disease progression and increased mortality,
increased maternal-fetal transmission
Iodine -> thyroid enlargement and hypothyroidism

Reduced Intake
HIV is associated with reduced intake of
Cognitive impairment and/or depression ->
reduced motivation and ability to access and
prepare foods
Family instability or poverty -> reduced access to
HIV-, OI-, or medication-induced -> anorexia and
OIs of mouth and esophagus -> painful swallowing

Reduced Absorption
HIV is associated with reduced
absorption of food/nutrients
Caused by HIV infection, OIs and ART
Mediated by diarrhea and damage to
intestinal cells
Results in poor absorption of fats
Reduces absorption of fat-soluble vitamins, such as
vitamins A and E


Altered Metabolism
HIV is associated with altered
metabolism of food/nutrients
HIV and OIs increase catabolism and
energy needs by 10 15%
Adult man needs an additional 400
calories/day (from 2100->2500)
Protein requirements increase by 50%
Men: 57 -> 85 of protein grams/day
Women: 48 -> 72 grams/day.

Effects of HIV on Nutrition:

Severe malnutrition in HIV-infected persons is
recognized as wasting, defined as:
Body weight loss of > 10%
With associated fatigue, fever, and diarrhea unexplained by
another cause

Etiology is multifactorial
Any weight loss of > 5% is associated with accelerated
disease progression, impaired functional status, and
increased mortality
Wasting is a WHO Stage 4 diagnosis and is a
criterion for ARV initiation

Vicious Cycle of Malnutrition and HIV

Source: Adapted from RCQHC and FANTA 2003

Poor Nutrition
resulting in weight loss,
muscle wasting, weakness,
nutrient deficiencies
Increased Nutritional
Reduced food intake
and increased loss of

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

Malnutrition and HIV/AIDS

Affect the body in similar ways
Affect the ability of the immune system to fight
infection and keep the body healthy through:


Disrupts CD4 number / function

Disrupts CD8 number / function
Alters delayed type cutaneous hypersensitivity
Alters CD4 / CD8 ratio
Impairs antibody response
Impairs bacteria killing

Malnutrition and HIV/AIDS (2)

Low BMI is associated with disease
progression and death
Nutrient deficiencies (vitamins A, B12, E,
selenium, and zinc) are associated with
worse outcomes
HIV transmission
Disease progression

Psychosocial Factors for

Food scarcity
Financial constraints
Family disruption
Loss of financial breadwinner
Loss of primary caregiver due to illness
or death
Mental health factors: depression


Goals of
Nutrition 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 of
Nutritional Care and Support

1. Nutritional
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?

Laboratory tests
Clinical assessments
Diet history and lifestyle

Anthropometric Measurements
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 Measurements
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
Serum insulin

Clinical Assessments in HIV/AIDS

Symptoms and illnesses associated
Diarrhea and vomiting
Fever (temperature)
Mouth and throat sores
Oral thrush
Muscle wasting
Fatigue and lethargy
Skin rashes
Palm pallor

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)


Stages of HIV Disease and

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

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

stage: Provide comfort

Advise on treating opportunistic infections
Counsel to modify diet according to symptoms
Encourage eating and physical activity

Nutrition Actions for HIVInfected 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

Diarrhea or malabsorption?


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

Source: Adapted from Hellerstein and Kotler 1998





DX Profile=abnormal
metabolism, relatively
high fat/lean ratio; low
RX=Make an exercise
plan, provide metabolic
steroids (?) and ARVs (?)

Etiology unknown
or unclear
RX=Continue to
feed and observe

Promote Adequate
Nutrient 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

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
Changes in food accessibility in terms of quality
and quantity (especially in resource-poor settings)

Promote Lifestyle Changes for

Nutritional Well-being
Eliminate foods and practices that aggravate

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 reducing
viral load or maintaining physical activity
Physical activity improves

Lean body mass

Body composition
Bone density
Functional capacity
Quality of life

Therapeutic Regimens
for HIV-Related Weight Loss


Rate of change in body

LBM (kg/wk) Weight (kg/wk)

Megestrol acetate




Parental nutrition








Nandrolone (hypogonadal)




Resistance exercise alone




Resistance exercise and





Source: Adapted from Hellerstein and Kotler 1998

That Build Muscle Mass
Weight bearing exercises
Resistance training
Weight training

Exercises generating high force on bone

Stair climbing

Relaxation exercises

Vitamin and Mineral Intake
Strategies to increase vitamin and mineral intake to
replenish or build body stores and optimize immune

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

Suggested Nutrient Supplement

Intake in HIV/AIDS
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 RDA (12-19mg)

Source: Serono 1999; Tang et al 1996. Excerpts from Eat up

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 > 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 Clients Well-being

Follow up
Integrate with other care and support activities where
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


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

Social: Support, stigma, gender roles,
education, information, traditions, beliefs
Economic: Household resources, food
security, financial access to health and
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 effectiveness

and 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

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
Hyperglycemia, insulin resistance, and glucose intolerance
Peripheral wasting (extremities, face)
Visceral and subcutaneous central adiposity (buffalo hump, breast

Managed by exercise training

and 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

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
Lifestyle changes (e.g., quitting smoking)

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

Symptom-based Nutrition
Care and Support

Managing the common symptoms that

occur with HIV/AIDS disease will
Maximize and improve nutritional intake
Maintain weight and muscle mass
Improve quality of life


Loss of Appetite
Eat small, frequent meals throughout the day
(5-6 meals/d)
Make every bite count
Drink plenty of liquids
Take walks before meals the fresh air helps
to stimulate appetite
Have family or friends assist with food
Mouth care is advisable

Sore Mouth and Throat

Avoid citrus fruits, and acidic or spicy
Eat foods at room temperature or cold
Eat soft and moist foods
Avoid caffeine and alcohol
Frequent mouth care


Nausea and vomiting

Eat small, frequent meals and snacks to avoid an
empty stomach
Eat dry bread or toast, and other plain dry foods, in the
morning preferably before getting out of bed
Avoid foods with strong or unpleasant odors
Avoid fried foods
Avoid alcohol and coffee
Drink plenty of liquids
Avoid lying down immediately (at least 1 to 2 hours)
after eating

Eat foods that travel slowly through the digestive
tract and decrease stimulation of the bowel
Bananas, mashed fruits, soft white rice, porridge

Eat smaller meals, more often

Eliminate milk and milk products to see if
symptoms improve
Avoid intake of fried and high fat foods
Dont eat foods with insoluble fiber (roughage)
For example: Take the skin off fruits and vegetables

Diarrhea (2)
Drink plenty of fluids (8-10 cups/day) to
prevent dehydration
Avoid sweet drinks, drink diluted juice instead
Avoid very hot or very cold foods
If diarrhea is severe
Give oral rehydration solution
Food may be withheld for 24 hrs or restricted to
only clear fluids (soups or tea) or soft foods
(mashed fruit, potatoes, white rice, porridge)

Drink plenty of fluids
Eat small frequent meals, including
snacks between meals
As tolerated at regular intervals

Mouth care is advisable

Add snacks between meals


Altered Taste
Use flavor enhancers such as salt and a
variety of herbs and spices
Try different textures of food
Chew food well and move it around the
This stimulates taste receptors


Poor Fat Absorption

Eliminate oils, butter, margarine, ghee, and
foods that contain or were prepared with
Eat lean meats
Trim all visible fat and remove skin from chicken

Avoid deep fried, greasy, and high fat foods

Eat fruits and vegetables and other low-fat


Fatigue, Lethargy
If possible, have someone pre-cook foods
This will help the patient conserve energy

Eat fresh fruits that dont require preparation

in-between meals
Eat smaller, more frequent meals and snacks
throughout the day
Exercise as able
This will increase energy

Try to eat at the same time each day.


Levels of Evidence
Evidence - Systematic reviews, metaanalysis
RCTs, EB clinical practice guidelines
based on RCTs
Evidence - One well designed RCT
III Evidence - CTs without randomization
IV Evidence - Well-designed case control or cohort
Evidence - Systematic reviews of descriptive or
qualitative studies
VI Evidence - Single descriptive or qualitative study
VII Evidence Opinions of authorities, reports

AACN Levels of Evidence

(Armola, et al. , C C Nurse, 2009)
Level A
Level B
Level C
Level D
Level E
Level M

Meta-analysis or metasynthesis of multiple

controlled studies, supporting a specific action
Controlled, randomized, or nonrandomized studies,
supporting a specific action
Qualitative, descriptive or correlational studies or
systematic reviews with consistent results
Peer-reviewed prof. organ. standards with studies
to support them
Theory-based evidence from expert opinion or
case studies
Manufacturers recommendations only

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