HIV and Nutrition

HIV and Nutrition Developed by Colette Nelson, MS, RD, CDE

Patient Nutrition Concerns • "How much protein should I eat?" • "Is it really important to eat vegetables so I can get these new phytochemicals I keep hearing about? Why can't I just take the supplements advertised on TV and in magazines instead of worrying about eating my vegetables?" • "Sugar? It can't be that bad--it seems to be added to everything I eat." • "If there is an HIV/AIDS diet that is scientific and not just a matter of opinion, why can't the nutritionists just give it to PWA/HIVs who really need it? • We have the Food Pyramid that the government says is the best way for the general public to eat. Why can't they do the same thing for an HIV disease diet?"

Issues in the Nutrition Profession • Difficulty with figuring out what is effective and what is the nutrition fad of the day. • Another problem is that approaches that show great promise for improving the health of PWA/HIVs but have a very low probability of profit are often very poorly studied.

General Nutrition Guidelines • High calorie/ high protein diet to help maintain weight • Provide adequate fluid, potassium when needed. • Increase Omega – 3 fatty acids • Small frequent feedings • Lactose or gluten are not tolerated • Sucrose , fat and D-xylose may also need to be limited • A general multi/mineral supplement may be indicated – 2-5X RDA ( Vit C, B12, Se, Vit A, Zinc, B- complex ) • Nutritious snacks may be beneficial • Increase green/orange vegetables • Food safety concerns • Modify diet with meds • Smoking & substance cessation

Goals of Nutritional Therapy • Determine what the person was like physically before becoming HIV-positive: Was he or she obese or heavily muscled? A couch potato or an athlete? On a good diet? • Help meet or exceed the amount of muscle the person had before becoming positive. Introduce the person to proper eating and exercise. • Help get the person back to her or his original weight, or to maintain it. • Teach about food and water safety. • Advise about the ability of food to ease some of the GI side effects of medications. • Teach the importance of maintaining eating and medication schedules to ensure maximum absorption of medications.

Major Nutrition Concerns • Prevent the development of specific nutrient deficiencies which can impair immune function • Prevent loss of lean body mass – wt loss > 60% of IBW death becomes a near certainty

Establish Baseline Status Infected with HIV (no signs of disease) • Eat a wide variety of healthy foods each day. • Try to choose all of your foods from the basic groups of foods described later in this information with an emphasis on protein. HIV infection is causing minor health problems • Eating may be uncomfortable or your appetite may be poor right now, but it is so important to eat well. • You may need to avoid certain foods & eat others or change the time that you eat or the amount that you eat can make you feel a lot better. HIV infection is causing serious health problems • You may even need assistance in shopping, cooking or eating. • You may need to consider nutritional supplements such as protein drinks, Peptimen, NuBasics, and other liquid meal replacements

What We Know About Nutrition • Nutritional status – predictor of survival & may help decrease disease progression • Malnutrition related to adverse outcome • 88% of PWA considered malnourished

Causes of Wasting • Malabsorption of fat and carbohydrates may develop even if symptoms are absent • Increased Excretion • Increased Requirements • Altered metabolism & high levels of cytokines • Low food intake • Proteins that produce inflammation in order to get rid of infection

Preventing Wasting • Nutrition Education • Appetite Stimulants • Anabolic Hormones

Concern About Calorie Requirements If you are able to maintain a stable healthy weight, you're eating enough calories Keep in mind that a stable weight does not indicate that you are necessarily maintaining your lean body mass; and this partly has to do with making sure you eat plenty of protein. For example You weigh 140 pounds and have lost 10 pounds in the last 6 months. You may need 25 calories per pound to gain weight: 140 x 25 = 3,500 calories per day

Calories Estimation of Calorie Needs: • 17-20 cal/lb if your weight is stable and there is no opportunistic infection • 20 cal/lb if you have an opportunistic infection • 25 cal/lb if you're losing weight

High Nutrient Foods

Protein Eat twice the RDA (Recommended Dietary Allowances) Protein: (1.0- 1.5 gm/kg BW) • Females: at least 100 grams of protein per day • Males: at least 125 grams of protein per day • Rule of thumb: Eat a good source of protein (meat, fish, poultry, eggs, dairy, beans) at least 5-6 times per day • For example, a reasonable goal would be to eat 30 grams per meal, in addition to two high-protein snacks

Protein Foods Meats, fish, poultry, eggs and cheese are in this group • They give you protein as well as many vitamins and minerals • Eat three servings or more each day One serving is considered to be • Two ounces of meat, fish, chicken or turkey. An ounce is the size of a slice of bologna or other cold cut. A typical chicken leg has about two ounces of meat on it. A typical hamburger patty is three ounces • Two eggs • Two slices of cheese or two 1-inch cubes • One cup of cooked beans or peas. This would be about the size of two scoops of ice cream. • Two handfuls of nuts • A thick coating of peanut butter on a typical slice of bread

Increase Protein in Your Diet • Include beans and tofu (soy) • Super fortify your milk- add several tbsp of dry milk solids, skim milk plus has 11gm vs. 8 gm of protein • Use lactose reducing labels if this is your main source of protein • Eat larger portions of meat, fish, poultry, eggs, milk, yogurt, cheese, dried beans • Choose deserts that contain eggs, milk, soy protein (ice cream, pudding, or custard • Add hard boiled eggs to tuna, diced meat to potato salad, cooked seafood, vegetables, salads • Add nonfat dry milk – casseroles, meatloaf, macaroni, meatballs, mashed potatoes, hot cereals

Increase Protein- Cont. • Add peanut butter or soy nut butter • Try cottage cheese- tofu, salads, vegetables, rice, pasta, soups, casseroles, tacos, burritos, toast • Prepare canned soups with milk, not water • Add chopped meat , cheese, ham to scrambled eggs, omelets, salads • Top fruit salad with yogurt, cottage cheese • NEVER EAT RAW EGGS-Caesar salad dressing, some desserts • If protein is a problem, try a predigested form of protein called peptides (Petamen meal replacement supplements) • Add grated cheese (nonfat has higher protein content)

Why Reduce Fat in Your Diet? Fat can be hard for your body to digest when you are sick, it can cause diarrhea, nausea, gas and bloating.

Fat: < 30% • Abnormal lipid metabolism; elevated triglyceride levels have long been recognized • Fat intolerance occurs – avoid high fat foods such as bacon, sausage, bologna, hot dogs, cream ice cream, whole milk, fried foods, mayonnaise, butter, margarine, sauces , oils, nuts.

Types of Fats Saturated Fats • Animal fats (butter, red meat,coconut, palm kernel oils, lard, hydrogenated oils) • Recently, both high triglyceride and cholesterol levels have been observed in some HIV+ people on antiretroviral therapy Polyunsaturated Fats: • Vegetable oils (corn & peanut oil, and in most margarines) • In some studies, polyunsaturated fats been shown to reduce T-cells, and with them the functioning of the immune system. Remain less likely to increase cholesterol than saturated fats

The Healthiest Fat Monounsaturated Fats • Found in vegetable oils like olive oil, canola oil, avocados, nuts, nut butters • Not suspected of being immune suppressive • Do not normally increase your cholesterol levels like saturated fats, but they are sometimes modified when heated during processing. For this reason, many people look for olive oil that is “cold pressed”

Omega-3 Fatty Acids • Essential fatty acids: must be present in your diet. Found in most fish and seafood, as well as in flaxseed and some beans and peas. • Reduce risk of heart attack and to have a positive influence on cell-mediated immunity (the part of the immune system most damaged by HIV infection).

Study : Omega-3 fatty acids • Reduced triglyceride levels and if they had no new opportunistic illnesses during the study, it helped them gain weight. • Many people with HIV who wish to supplement their food intake of omega-3 fatty acids take omega-3 fish oil supplements (about 3 g daily).

Omega-3 Warning: • Make sure these fish oil supplements are not cod liver oil, or any other fish oil containing vitamins A and D. • Vitamins A and D should be removed from omega-3 fatty acid supplements because the usual doses may result in an excessive intake of these vitamins.

Low-Fat Suggestions • Try reduced fat foods or fat free • Substitute mashed, boiled, or baked for french fries • Use seasoning to sauces or gravies to improve taste and moisture • Low fat yogurt, low fat cottage cheese, skim milk (try Plus ), buttermilk. • Hot and cold cereals. No granola. • Toast with jelly or honey. No butter or margarine. • Soups with broth. No cream soups.

Low-Fat Suggestions • Tuna packed in water. No tuna packed in oil. • Foods which are baked, broiled, boiled, stewed, grilled or roasted. No fried foods. No french fries. No doughnuts. No fried chicken or fried fish. • Pretzels and plain crackers. No chips. • Plain cooked vegetables. No cream sauce, butter, margarine or meat fat added. • Fresh fruit and fruit juice.

Low-Fat Suggestions • Puddings made with skim milk. • Sherbet, Popsicles, fruit ice. No ice cream. • Angel food cake. • No pound, layer or cheese cake. • Hard candy, jelly candy. No chocolate bars. • Vanilla wafers, ginger snaps, graham crackers. • Fat-free chili, spaghetti and soups, refrigerating overnight to make the fat get hard on top. Then you can remove it easily. • Mustard vs. mayonnaise or salad dressing. • No peanut butter.

The Use of MCT Oil • Try substituting with MCT oil- it is easier to digest and absorb • MCT OIL, comes from “ fractionated coconut oil”, which means broken down coconut oil, it is not the same as the usual highly saturated coconut oil • Use MCT oil while on a low-fat diet and it is treated more like a carbohydrate

Fruits & Vegetables • Salads, cooked vegetables, raw or cooked fruits and juices are in this group. • They supply many of the vitamins and minerals your body needs. • Eat four servings or more each day. • One serving is considered to be: • A piece of fruit or raw vegetable. • A half cup of cooked vegetable or fruit. This would be like the size of a scoop of ice cream. • A small glass of juice.

Carbohydrates Bread, grains and cereals are in this group • They have a variety of vitamins, minerals and some protein in them. • Eat four servings or more each day. One serving is considered to be: • One slice of bread – choose whole grains • One bowl of breakfast cereal > 5 gm of fiber • One half cup of noodles, macaroni, rice or grits. This would be like the size of a scoop of ice cream. A typical plateful of spaghetti would be two or more servings. • One pancake, waffle, tortilla or slice of cornbread • One biscuit • 5 crackers

Dairy Products Milk, cheese and yogurt are in this group • They give you protein, vitamins and a lot of calcium. Eat two servings or more each day. One serving is considered to be: • 8 ounce glass of milk. This is about the size of a coffee mug. • 8 ounces of yogurt. This is the size of the typical container of yogurt at the store. • Two slices of cheese, or two 1-inch cubes. • One bowl of pudding or custard, the size of a cereal bowl. • One and one half cups of ice cream. This would the amount in three scoops, or three ice cream bars.

Lactose Intolerance You should not eat these foods: • Regular (whole) milk, skim milk, low fat milk, evaporated milk • Powdered milk , goat milk • Cheese (unless label says it has been aged 90 days) • Instant coffee, cocoa or other chocolate beverages • Whipping cream, sour cream • Pudding and pudding pies • Custard and custard pies • Ice cream or ice milk • Gravy made with milk or cream • Soups made with milk or cream • Party dips made with sour cream • Cream sauce on meats or vegetables

You Might Be Able to Use These Foods Instead • Sweet acidophillus milk (it says "acidophillus" on the label) • Lactose-reduced milk (it says "lactose reduced" on the label) • Buttermilk • Regular milk with "Lact-aid" added to it. You can buy Lact-aid at drug stores. It is a powder you add to milk. It digests the lactose for you and the milk tastes just fine • Natural cheese which has been aged for 90 days or longer. Many cheddar and Swiss cheeses are aged for 90 days. Just read the label more...

You Might Be Able to Use These Foods Instead • Yogurt , frozen yogurt desserts , Sherbet • Powdered coffee creamer such as "Coffee mate." You can use this in place of milk in many recipes. • Soybean milk. You can buy this canned at drug stores and at many grocery stores. Try soybean infant formulas ("Prosobee," "Nursoy," or "Isomil"). • Special dietetic products that say "lactose free" on the label. • Kosher foods marked "pareve" are milk-free.

Liquid Supplements • Allow you to get a large amount of calories in one glass of liquid. • Supplements which contain MCT (medium chain triglycerides) may be preferable because they are easier to absorb than those that contain the more common long chain triglycerides. • Look for a liquid supplement that is as high in protein as possible.

Commonly Used Liquid Supplements • Instant Breakfast • Slender ® • Ensure®;Sustacal®;Enrich®; • Magnacal®;Ensure Plus®;Repleat®; Nutrament®;Alba®;Meritene®;Citrotein® • Nutri1000®;Resource®;

Techniques in Mixing Liquid Supplements • Increase the protein content of a liquid supplement by sprinkling whey protein or other protein powder into the supplement. • Choose to take just whey protein or soy protein powder to increase protein intake thus avoiding the diarrhea that may be caused by the long chain fats in many liquid supplements. • Some provincial and private insurers cover the cost of a limited selection of liquid supplements

Enteral Nutrition • This is a fairly uncommon way of dealing with HIV related weight loss. • It is generally done via a nose tube if a person is having trouble swallowing or breathing, or if someone is too sick to eat. • If the treatment is expected to be long term, a tube may be inserted through the abdominal wall directly into the stomach. • This allows a person who cannot eat an adequate diet to use enteral nutrition on an ongoing basis, probably at home. This procedure is of more limited value in the case of severe malabsorption, however special formulas of an elemental diet are available for people experiencing malabsorption or diarrhea.

Total Parenteral Nutrition • Allows nutrients to be delivered directly into the blood stream with an intravenous tube. • This is an uncommon way to treat HIV+ people because it is extremely expensive, however, it may be useful during periods of serious illness. • This is particularly appropriate for illnesses that affect the gastrointestinal tract and prevent normal food intake. • Severe malabsorption with uncontrollable diarrhea may be treated in this way in rare instances

Nutritionist View on Supplements • Nutritionist agree on emphasizing the need to eat food and drink water first, when possible, and to use supplements as supplements, not as main courses.

Common Deficiencies • Vitamin A, zinc, iron- detrimental to the immune function • Depletion of antioxidants- Vit A, Vit. C, and B vitamins can also compromise immune function b/c of their roles as cofactors in many enzyme functions including those involved in nucleic acid synthesis

Vitamin/Mineral Toxicity • Beware of excess iron or zinc, vitamin E and PUFA because of their effect on immunity when taken in large doses • Potential iron is not appropriate in cachexic patients, or in sepsis, expect in careful consideration by physician.

What About Supplements? • Start with a diet with lots of variety and many different colors of vegetables • A multi-vitamin taken once or twice a day with meal • NAC and higher doses B vitamins • Regular injections of vitamin B12 • Higher doses of other vitamins like C, E, and the mineral selenium

Guidelines: Taking Vitamins • Take a daily multi-vitamin and mineral pill. - Look for one that includes iron. • Pills cannot make up for not eating right. When you are infected with HIV, your body may need the extra vitamins and minerals that you get from both healthy food and a vitamin/mineral pill. • It is better to take one multi-vitamin and mineral pill each day than to take several pills containing different vitamins and minerals. These can cause dangerous side effects.

Guidelines: Taking Vitamins (cont.) • The most expensive may not be the best- look for USP government inspection • It is not Important for a vitamin to be "natural" instead of synthetic. Your body can't tell the difference. • No such thing as a special vitamin pill for HIV or AIDS. • The vitamins and minerals in pills work best in your body when taken with a meal- try taking with largest meal which may be in the evening

Vitamin/Mineral Drug Interactions • Iron supplements may decrease the absorption of tetracyclines and other antibiotics • Zinc and copper interact; when taking large quantities, take separately • Isoniazid (a TB drug) increases the need for Vitamin B6 • The antibiotic ciprofloxicin should not be taken within 2 hours of calcium, iron magnesium or aluminum supplements because absorption is decreased • Agenerase has a significant amount of Vitamin E (109 IU) to improve it's bioavailability, this may interfere with blood thinning medications

Poor Appetite Eat very small meals many times during the day. How small? Here is a sample menu: Breakfast: 3 crackers with peanut butter and a 1/2 cup of apple juice Snack: 1 carton yogurt Lunch: 1/2 ham and cheese sandwich, 1 cup cocoa Snack: 2 oatmeal cookies, glass of milk Supper: cottage cheese with canned peaches Snack: 1 bowl of cereal and milk

Poor Appetite (cont) • Watch the clock. Eat something every hour or two whether you feel like it or not. • Eat food that you really love at this time. Spaghetti and meatballs, pizza, and tacos are favorites for many people. • If you can find one thing you enjoy eating, just eat it all day. • Sometimes you can't eat solid food but you'll be able to drink things. Try milkshakes. Try ice cream floats--mix ice cream with your favorite juice or soft drink in a tall glass. You might also try chocolate milk, egg nog or hot cocoa. Creamy soups might go down easy as well. • Keep snacks right beside you in your home. You might be able to nibble enough to finish quite a bit of food.

Weight Loss • Increase the number of times you eat each day. • Eat more foods that are high in calories and protein, such as milk, cheese, meats, and peanut butter. • Make your snacks count. Eat healthy foods high in calories and protein between meals. • Add extra fat to your food. It can increase calories a lot without your having to eat a larger amount of food.

Weight Loss (cont.) • Add sugar, honey, syrup, brown sugar and other sweet things to your food. Put jams and jellies on breads, toast, rolls, pancakes and waffles. Put sugar or honey in your coffee and tea. Add it to your cereal. • Eat dried fruit such as raisins, prunes, dried apricots, dried apples, dried peaches, figs and dates. These are good by themselves or mixed with nuts for a snack. Add them to hot cereal such as oatmeal and cream of wheat.

HIV and Nutrition