HIV Nutrition & Health Benefits

1. HIV Nutrition& Health Benefits Jenn Messina, RD HIV/AIDS Program St. Paul’s Hospital, Vancouver February 7th, 2013

2. Outline Personal intro HIV Globally Nutritional issues in HIV Asymptomatic & symptomatic infection Provincial health benefits Questions

3. Personal Introduction • UBC Integrated Internship • Graduated UBC in 2007 • Currently working in the Immunodeficiency Clinic, St. Paul’s Hospital, Outpatient Clinic • B.C. Centre for Excellence in HIV/AIDS Care

4. HIV Global Statistics The number of people living with HIV (including AIDS) continues to rise 34 million people were living with HIV/AIDS worldwide at the end of 2011 In Canada it is prevalence of HIV has risen from an estimated 64,000 in 2008 to 71,300 in 2011 (an 11.4% increase) It is estimated that between 2,250- 4100 new HIV infections occur in Canada each year

5. Nutritional Issues Malnutrition and wasting Loss of appetite Gastrointestinal complications Side effect of medications Metabolic abnormalities Mental health Disordered eating Substance use Socioeconomic factors- food insecurity Special needs groups: pregnancy, children, adolescents

6. HIV Nutrition Assessment • Anthropometrics: • Height, weight, BMI, weight history • Biochemical: immune status, lipid profile, fasting blood sugar, renal status, nutritional labs, bone density (if available) • Clinical: • Patient medical history, medications, social history • Diet history: • Intake of key nutrients e.g. energy, protein, fat, fibre, calcium, vitamin D • Knowledge, beliefs • Allergies, intolerances • Supplement intake • Physical activity • Food security • Food/support resources

7. Symptomatic & Asymptomatic HIV Infection Symptomatic HIV infection: • Fever • Opportunistic infections, e.g. Pneumocyctis iirovecii pneumonia, (PCP), cytomegalovirus (CMV), and Mycobacterium avium (MAC), have nutrition implications • Oral thrush • Weight loss Usually CD4+ T helper cells <200 Asymptomatic infection: a phase of chronic infection which the person does not display symptoms Usually CD4+T helper cells >200

8. Symptomatic HIV Infection HIV Associated Weight Loss • Inadequate nutrient intake • Oral and upper GI symptoms • Anorexia • Psychosocial • Malabsorption • Altered metabolism • Uncontrolled HIV infection • AIDS defining illnesses

9. HIV Wasting Syndrome HIV Wasting: Infection induced cachexia characterized by inappropriate catabolism of skeletal or other lean proteins Centre for Disease Control definition: Involuntary weight loss >10% (of baseline body weight) associated with either chronic diarrhea (two or more loose stools per day for ≥1 month) or chronic weakness and documented fever for ≥1 month

10. Symptomatic HIV Infection Caloric recommendations: • 20-30% higher than non-infected person with same age, sex, physical activity to maintain weight Affected by age, activity level, HIV status, nutritional status, infection, comorbidities, etc. • Initiation of anti-retroviral therapy may also increase energy needs as the individual transitions to a anabolic state • Metabolic cart is the gold standard • Protein recommendations: • 1.5- 2g protein/kg/day • Needs to be individualized

11. Symptomatic HIV: Recommendations • HIV control and treat concurrent infections • Addressing psychosocial factors, depression • Diet counseling: • Symptom management of GI side effects • High calorie, high protein diet • Homemade/commercial nutrition supplements • Nutrition support (tube feeding) in hospital may be needed • Address food security, community resources, funding, connect with RD as needed if in hospital

12. Asymptomatic Infection Caloric recommendations: • 10% higher than non-infected person with same age, sex, physical activity to maintain weight • Affected by age, activity level, HIV status, nutritional status, infection, comorbidities, etc. Protein recommendations • 1.0- 1.2g protein/kg/day when stable • Needs to be individualized

13. Asymptomatic recommendations Nutrient rich, balanced diet Individual energy, protein, micronutrient needs Food and Water safety Encourage exercise Ensure food security Address any nutritional issues identified Consider social factors affecting healthy eating

14. Metabolic Complications of HIV Dyslipidemia Insulin resistance Reduced bone density

15. Dyslipidemia and Insulin Resistance Therapeutic lifestyle and diet are the first line strategy Traditional approaches to treat dyslipidemia and hyperglycemia should be initiated Dietitian counselling works best if it is regular and sustained

16. Bone Health: Screening, Prevention & Treatment • HIV positive people at higher risk for osteopenia and osteoporosis, cause ismultifactoral • Assess • Determine if risk further increased with traditional risk factors i.e. menopause, underweight/obese, medications, diet • Prevention • Adequate calcium and vitamin D depends on age • Maintain healthy body weight • Nutrient treatment • 1000-1200 mg calcium • 1000 IU vitamin D (?more)

17. Ministry of Social Development (MSD) Provincial Nutrition Programs

18. Types of Health Supplements • Diet Supplement (also known as ‘Diet Allowance’) • Short Term Nutritional Supplement • Monthly Nutritional Supplement • Other Health Supplements

19. Diet Supplements • Diet supplements assist clients to meet costs associated with an unusually expensive therapeutic diet that is required as a result of a specific medical condition or a special dietary need. • A diet supplement may provided for a maximum of 12 months for acute (short-term) conditions and 24 months for chronic (ongoing, recurring, long-term) conditions Eligibility: For those on MSD income assistance & disability assistance http://www.eia.gov.bc.ca/mhr/hsp.htm

20. Diet Supplements Monthly Allowance: • $10: Restricted sodium diet • $35: Diabetes • $30: Kidney dialysis • $40: High protein diet (plus $30 towards the purchase of a blender) • $40: Gluten-free diet • $40: Dysphagia (plus $30 towards the purchase of a blender) • $40: Ketogenic diet • $40: Phenylalanine diet • $50: Cystic fibrosis Note: If client has multiple medical conditions- highest amount ‘trumps’ and only 1 diet supplement will be given

21. Diet Supplements Funding for high-protein diets is available for individuals who need additional nutritional support and have been diagnosed with: • Cancer (requiring nutritional support during radiation, chemotherapy, surgical cancer therapy) • Chronic inflammatory bowel disease • Crohn's disease • Ulcerative colitis • HIV/AIDS, chronic bacterial infection and tuberculosis • Hyperthyroidism • Osteoporosis • Hepatitis B or hepatitis C. http://www.gov.bc.ca/meia/online_resource/health_supplements_and_programs/dietsupp/policy.html

22. Diet Supplements • To be eligible for a diet supplement, recipients must provide written confirmation of the need for the diet supplement from a medical practitioner, nurse practitioner or from a dietitian who is registered with the College of Dietitians of British Columbia • Diet allowance form available through MSD • Letter can also be done and include: • the specific medical condition • the diet required • expected duration of need http://www.gov.bc.ca/meia/online_resource/health_supplements_and_programs/dietsupp/faqs.html

23. Diet Supplements HIV/AIDS Program St. Pauls Hospital 1081 Burrard Street Vancouver, B.C. To Whom It May Concern at the Ministry of Social Development: Re: Jane Smith DOB: 1/1/1951 My client is HIV positive and requires a high protein diet to help improve nutritional status. Please provide the $40 High Protein Diet Supplement and the initial $30 for purchase of a blender. She will need this diet supplement for 2 years, the maximum allowable time for a chronic condition as she will require this diet as long as she is living. Sincerely, Jenn Messina, CDBC #1046 Clinical Dietitian 604-682-2344 ext 62641

24. Short-term Nutrition Supplement • Nutritional supplements may be for those who need additional calories above a regular diet to recover from surgery, severe injury, serious disease, or the side effects of medical treatment • Eligibility: for those on MSD income assistance & disability assistance http://www.gov.bc.ca/meia/online_resource/health_supplements_and_programs/nutsupp/

25. Short-term Nutrition Supplement • To be eligible for a nutritional supplement, recipients must provide written confirmation of the need from a medical practitioner or nurse practitioner • Include: • The diagnosis • The reason the product is required • The name of the product required, the amount of product required and the expected duration of need (up to a maximum of 3 months) Letter must confirm acute, short-term need to prevent critical weight loss For those on MSD income assistance & disability assistance, but NOT getting Monthly Nutritional Supplement (MNS) http://www.healthlinkbc.ca/healthyeating/bc-nutrition-programs.html

26. To whom it may concern at the Ministry of Social Development, Re: John Smith Date of birth: 1/1/1951 I am writing as the dietitian for the Immunodeficiency Clinic where John Smith attends for his medical care. John is being followed by the dietitian due to malnutrition and weight loss due to his advanced lung cancer with bone metastasis. This person is also HIV positive and on anti-retroviral therapy for immune reconstitution and viral suppression. John has lost 7.6kg over the past few months, 12% of total body weight, and has visible muscle wasting. His BMI is low at 18.2. Weight loss occurred during his radiation therapy for his cancer and he has had ongoing poor appetite, nausea and weight loss after this therapy has been completed. He is at ongoing high nutrition risk due to upcoming chemotherapy cancer treatment. He urgently requires 3 bottles of Ensure Plus daily for 3 months to optimize his oral intake, prevent further weight loss, malnutrition, and muscle wasting. Malnutrition and unintentional weight loss increase the risk of morbidity and mortality in HIV positive people. Please call me with any questions or concerns. Thank you. Jenn Messina, Clinical Dietitian Dr. Sarah Stone CDBC #1046 Short-term Nutrition Supplement

27. Monthly Nutritional Supplement The Monthly Nutritional Supplement is monetary allowance to financially assist those who have a severe medical condition causing a chronic, progressive deterioration of health with symptoms of wasting. This supplement is intended to prevent imminent danger to the person’s life by providing essential, specified items to supplement regular nutritional needs Eligibility: for those on MSD Disability Assistance ONLY

28. Monthly Nutritional Supplement Written confirmation by the recipient’s medical practitioner or nurse practitioner is needed to confirm: 1) the person has a severe medical condition causing a chronic, progressive deterioration of health 2) as a result of this deterioration of health, the person displays two or more of the following symptoms: • malnutrition • underweight status • significant weight loss • significant muscle mass loss • significant neurological degeneration • significant deterioration of a vital organ • moderate to severe immune suppression http://www.gov.bc.ca/meia/online_resource/health_supplements_and_programs/mns/policy.html

29. Monthly Nutritional Supplement 3) to alleviate these symptoms, the person requires one or both of the following items: • additional nutritional items that are part of a caloric supplementation to a regular dietary intake • vitamins and minerals 4) failure to obtain these items will result in imminent danger to the person’s life

30. Monthly Nutritional Supplement How to Apply: • Client needs to pick up “Monthly Nutritional Supplement Application form” from MSD • MSD needs to complete part A • Client needs to sign part B • RD/MD/NP completes part C

31. Monthly Nutritional Supplement Tips and tricks for a successful form • Make sure to discuss the form first with the persons MD/NP, they take a lot of time! • Be specific for vitamins and minerals • Leave the ‘duration of need’ open ended if you aren’t sure the time frame they may need items for • Don’t ‘overpromise’

32. Monthly Nutritional Supplement Tips and tricks for a successful form

33. Other Supplements • Tube feed supplement: provides liquid nutritional tube feed, equipment and supplies to those who are unable to take food orally or process it through GT tract Eligibility: on MSD income assistance or disability http://www.gov.bc.ca/meia/online_resource/health_supplements_and_programs/tubesupp/policy.html • Department of Veteran's Affairs (DVA): May cover tube feed supplements/supplies depending on coverage 1-866-522-2122 (English) or http://www.veterans.gc.ca/eng

34. First Nations Some bands will cover a short-term supply of Ensure/Boost • Individual bands vary with coverage, speak with health department of band department For Status First Nations: Tube feed formula /supplies and liquid supplements for some patients. MD to write a prescription and fax to pharmacy. Local pharmacy will then fax ‘letter of exception’ for Non-insured health benefits (NIHB) program to MD to complete. For further information call NIHB at 1-800-317-7878 http://www.hc-sc.gc.ca/fniah-spnia/pubs/nihb-ssna/yhb-vss/index-eng.php

35. Resources • CATIE: www.catie.ca • Position Statement ADA HIV Nutrition • The Body: www.thebody.ca • Ministry of Social Development: http://www.gov.bc.ca/hsd/ • AIDS Vancouver: www.aidsvancouver.org • Positive Living BC: www.positivelivingbc.org • DIAC (Dietitian’s in AIDS Care) Practice Group

36. Good Articles/Resources • B.C. Centre of Excellence in HIV/AIDS. (1997). The therapeutic guidelines for the treatment of HIV/AIDS and related conditions: Section 9: Therapeutic nutrition guidelines. Vancouver, B.C. • Food and Nutrition Technical Assistance Project. (2004). HIV/AIDS: A guide for nutritional care and support, 2nd Edition. Academy for Educational Development, Washington, DC. • Gerrior, J. & Neff, L. (2005). Nutrition assessment in HIV infection. Nutrition in Critical Care, 8 (1), 6-15. • Holick, M.F. et al (2011). Evaluation, treatment and prevention of Vitamin D deficiency: an Endocrine Society clinical practice guideline. Journal of Clinical Endocrinology Metabolism, 96,7, 1911-1930. • Mangili, A., Murman, D., Zampini, M, and Wanke, C. (2006). Nutrition and HIV infection: review of weight loss and wasting in the era of Highly Active Antiretroviral Therapy from the Nutrition for Healthy Living Cohort. Clinical Infectious Diseases, 42, 836-842. • McComsey, G.A. et al (2010). Bone disease in HIV infection: A practical review and recommendations for HIV Care Providers. Clinical Infectious Diseases, 51, 8, 000-000. • Pribram, V. (2001). Nutrition and HIV. Oxford, U.K: Blackwell Publishing. • Ockenga, J. et al. (2006). ESPEN guidelines on enteral nutrition: wasting in HIV and other chronic diseases. Clinical Nutrition, 25, 319-329. • World Health Organization. (2003). Nutrient requirements for people living with HIV/AIDS: Report of a technical consultation. Geneva, Switzerland.

37. Acknowledgements • Cheryl Collier, HIV RD at Oaktree Clinic • Alena Barron, HIV RD at St. Paul’s 10C • Clients of 10C, IDC, and Providence Crosstown Clinic

38. Questions?Contact: jmessina@providencehealth.bc.ca