Key Nutrition Actions for People Living with HIV/AIDS

1. Key Nutrition Actions for People Living with HIV/AIDS Nutrition and HIV/AIDS: A Training Manual Session 3

2. 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

3. 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

4. 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

5. Components ofNutritional Care and Support • Nutritional assessment • Intervention • Follow up and review

6. Nutritional Assessment

7. 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

8. What to Measure? • Anthropometry • Laboratory tests • Clinical assessments • Diet history and lifestyle

9. Anthropometric Measurementsin 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])

10. 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

11. 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

12. 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)

13. Interventions

14. 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

15. 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

16. 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

17. Energy intake? Diarrhea or mal-absorption? Metabolic parameters Etiology unknown or unclear RX=Continue to feed and observe OK NO Normal Abnormal YES 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 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 (?) Algorithm for Managing Weight Loss in Patients with HIV/AIDS Source: Adapted from Hellerstein and Kotler 1998

18. 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

19. 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)

20. 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

21. 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)

22. 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

23. Therapeutic Regimensfor HIV-Related Weight Loss Source: Adapted from Hellerstein and Kotler 1998

24. 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

25. IncreaseVitamin 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

26. Suggested Nutrient Supplement Intake in HIV/AIDS Source: Serono 1999; Tang et al 1996. Excerpts from Eat up

27. 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

28. 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

29. Follow up and Review

30. 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

31. Factors to Consider in Care and Support of People Living with HIV/AIDS

32. 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

33. Nutritional and Antiretroviral Therapy

34. 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

35. 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)

36. Educate on Nutrition-Related Side Effects of ARVs • Lipodystrophy (fat maldistribution) • Hyperglycemia/insulin resistance • Hyperlipidemia

37. 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

38. Hyperglycemiaand 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

39. 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 • Lifestylechanges (e.g., quitting smoking)

40. 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

41. 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