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Ninuk D.

Learning Objectives
Describe the effect of HIV/AIDS on
nutrition
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
people
Describe appropriate assessments,
interventions, follow-up and review for
nutritional care in HIV/AIDS

Learning objective
Describe evidence-based nutritional care
for PLWHIV

Evidence-based Nutritional
Care

Malnutrition and HIV

Malnutrition and HIV


Malnutrition and HIV are prevalent worldwide
with the highest rates of both in sub-Saharan
Africa
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
10

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

11

Protein-Energy Malnutrition
(2)
Used to describe nutritional macrodeficiency
syndromes
Marasmus: deficiency of calories
Kwashiorkor: deficiency of protein
Nutritional dwarfism in children and wasting syndromes in
adults

Measured as body size by weight or body mass index


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

12

< 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
severe
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
13

Nutrition:
Reduced Intake
HIV is associated with reduced intake of
food/nutrients
Cognitive impairment and/or depression ->
reduced motivation and ability to access and
prepare foods
Family instability or poverty -> reduced access to
food
HIV-, OI-, or medication-induced -> anorexia and
nausea
OIs of mouth and esophagus -> painful swallowing
14

Nutrition:
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

15

Nutrition:
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.
16

Effects of HIV on Nutrition:


Wasting
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
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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
needs
Reduced food intake
and increased loss of
nutrients

HIV
Increased vulnerability to
infections e.g. Enteric
infections, flu, TB hence
Increased HIV replication,
Hastened disease progression
Increased morbidity
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Impaired Immune System


Poor ability to fight HIV
and other infections,
Increased oxidative
stress

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:

19

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
Mortality
20

Psychosocial Factors for


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

21

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
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 Measurements
in 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 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)

Interventions

Stages of HIV Disease and


Nutrition
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
Late

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
Energy
intake?

OK

LOW

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?

YES

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

Source: Adapted from Hellerstein and Kotler 1998

NO

Metabolic
parameters

Normal

Abnormal

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

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


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
Consider
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)

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 reducing
viral 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
Weight training

Exercises generating high force on bone


Aerobics
Jogging
Stair climbing
Hiking
Skipping

Relaxation exercises
Yoga

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

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

1,500-2,000mg

Selenium

200mcg

Zinc

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
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 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
Hyperlipidemia

Lipodystrophy
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

Hyperglycemia
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
action

Hyperlipidemia
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)

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

60

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
preparation
Mouth care is advisable
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Sore Mouth and Throat


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

62

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
63

Diarrhea
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
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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)
65

Fever
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

66

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
mouth
This stimulates taste receptors

67

Poor Fat Absorption


Eliminate oils, butter, margarine, ghee, and
foods that contain or were prepared with
them
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
foods.

68

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.


69

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

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

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