Medical Nutrition Therapy for Human Immunodeficiency Virus (HIV) Disease

1. Chapter 41 Medical Nutrition Therapy for Human Immunodeficiency Virus (HIV) Disease

2. Human Immunodeficiency Virus • HIV is a virus that targets the body’s immune system and inhibits a person’s body from producing adequate immune defenses. • This virus can develop into AIDS over time.

3. Acquired Immunodeficiency Syndrome • AIDS is the final stage of HIV. • AIDS is a disease that prevents the body’s ability to fight off infection and illness.

4. HIV and AIDS • Opportunistic infections and rare skin cancer, Kaposi’s sarcoma, depressed cellular immunity are common. • HIV virus destroys the T helper cells or T4. • Acute phase of infection 2 wks; 8 wks later, test positive for HIV infection

5. HIV Infection • 30% to 60% develop an acute syndrome with malaise, fever, pharyngitis, lymphadenopathy, headache, myalgia, and sometimes a rash

6. Risk Factors for Contracting HIV • HIV can be transmitted through four different types of fluids that can enter the bloodstream 1. Blood 2. Semen 3. Vaginal fluids 4. Breast milk (mother) • Fluids such as saliva, sweat, tears, and urine do not transmit the virus, but HIV antibodies may be present in these fluids.

7. People at Risk for HIV • Heterosexuals with more than one sex partner • Hemophiliacs—inability to clot blood • These people have many blood transfusions. • Homosexual or bisexual males • Intravenous drug users • Infants with HIV-positive mothers

8. Acquired Immunodeficiency Syndrome • Diagnosed when a person has HIV infection and CD4 cell count below 200 or less than 14% • Dementia, wasting syndrome, malignancies such as Kaposi’s sarcoma, or one of more than 26 opportunistic infections

9. Diagnosis of HIV and AIDS • Tests • ELISA an immunosorbent assay—Check for antibodies of HIV (2 weeks’ postexposure) – Western blot—more accurate but not 100% – Polymerase chain reaction (PCR)—detects viral nucleic acids in virus; most sensitive

10. Symptoms of HIV and AIDS • Early: fever Weight loss Diarrhea Flulike • Later: opportunistic infections Malignancies

11. Common Problems in HIV/AIDS • Fungus infections: thrush • Meningitis • Pneumonia • Protozoal infections—infection in large and small bowels • Viral infections—herpes; shingles

12. Lipodystrophy • Reported among people taking any of the licensed protease inhibitors • Disturbed fat metabolism • Loss of thin layer of fat; veins protrude • Wasting of face and limbs • Accumulated fat in abdomen under skin and inside body cavity or between shoulder blades

13. HIV Medical Management The goals of medical management of HIV are to: • Prolong life and improve the quality of life for the long term • Suppress the virus to as low a level as possible for as long as possible • Optimize and extend the usefulness of currently available therapies • Minimize drug toxicity and manage side effects

14. Nutritional Assessment • Nutritional assessment: necessary for detecting and reducing HIV and AIDS malnutrition • After diagnosis of HIV, nutritional screening should be performed immediately while still clinically asymptomatic. • Through biochemical measurements, serum levels of vitamins and minerals can be obtained to identify micronutrient deficiencies. • Three major components of nutritional assessment include medical diet history, physical assessment, and laboratory studies.

15. Nutritional Assessment—cont’d • Serum proteins can be measured to assess visceral protein status. • Measuring cellular levels of nutrients such as liver store of vitamin A or leukocyte levels of vitamin C may be a valid method of assessing body stores. • Hypoalbulminemia is associated with reduced survival in people with AIDS.

16. Nutritional Assessment—cont’d • Percent UBW more important than percent IBW—patients don’t lose fat as much as lean • TLC and delayed cutaneous hypersensitivity not helpful

17. HIV Assessment • Baseline status at diagnosis • Follow and reassess as complications develop • Consider mental status • Misinformation • Knowledge of food sanitation and good nutrition

18. General Goals of Nutrition Intervention in HIV Disease • Preserve optimal somatic and visceral protein status • Prevent nutrient deficiencies or excesses known to compromise immune function • Minimize nutrition-related complications that interfere with either intake or absorption of nutrients • Support optimal therapeutic drug levels • Enhance the quality of life

19. Nutritional Goals • A combination of nutrition support and drug therapy allows people with HIV and AIDS to live longer, better-quality lives. • Maintain good nutrition and exercise to improve health and slow down HIV infection. • Prevent weight loss.

20. Medical Nutrition Therapy Requires Six Distinct Components • Screening • Referral • Assessment • Intervention • Outcomes evaluation • Communications

21. Management of Symptoms in HIV/AIDS • Nausea and vomiting • Loss of appetite • Sore mouth and throat • Diarrhea • Poor absorption of nutrients • Abdominal cramping • Weight loss

22. Eating Tips for Common Symptoms • Lack of appetite —Eat favorite foods often. —Eat snacks or a small meal every 2 to 3 hours. —Go for a short walk or exercise to boost appetite. • Nausea and vomiting —In the morning eat crackers, dry toast, or dry cereal. —Avoid greasy, fried, or very sweet foods such as french fries, pastries, and ice cream. —Sip on flat sodas, weak ginger tea, or mint tea.

23. Eating Tips for Common Symptoms—cont’d • Sore mouth and throat —Try soft smooth foods, like mashed potatoes, applesauce, baby foods, and cream soups. —Avoid foods that sting or irritate the mouth, like orange or tomato juice, hot sauces, and salty foods. —Eat cold foods, such as Popsicles or ice cream. • Diarrhea —Eat foods like bananas, applesauce, rice, and gummy candy. —Cut back on fatty foods. —Cut down on fiber in the diet.

24. Suggested Diets for HIV/AIDS Patients • Diets rich in fruits and vegetables that includes iron, vitamin E, and riboflavin may delay the development of full-blown AIDS. • There have been many alternative therapies that include nutrition-based options such as megadoses of nutrients, Dr. Berger’s Immune Power Diet, and macrobiotic diet. • Most of these diets are low in fat and calcium and high in fiber. They have not been proven effective.

25. Roles of the Dietitian • Guiding the patient with emotional support, proper nutrition, and incorporating exercise into the daily routine are some of the challenges dietitians face. • Monitor body composition and hormone levels to improve body composition. • Monitor blood lipid, sugar levels, diet, and medications to prevent hyperlipidemias and elevated blood sugars.

26. Wasting Syndrome • Wasting syndrome is defined as the unexplained weight loss of more than 10%, and is accompanied by fever or diarrhea for 30 days. • It is considered a condition that is an indicator for AIDS. • It is a multifactorial condition that can be associated with variety of infectious, neoplastic, metabolic, and nutritional abnormalities.

27. Nutritional Calculations • Energy—HB for BEE Add injury factors x 1.3 maintenance or 1.5 weight gain • Protein 1 to 1.4 g/kg/day maintenance 1.5 to 2.0 g/kg/day repletion • Fat—adjust for malabsorption

28. Nutritional Calculations—cont’d • Fluids and electrolytes Consider symptoms and replace for fever, diarrhea, night sweats, vomiting • Vitamins and minerals Increased needs for ß-carotene, E, C, B12, B6, folate

29. Food Safety Suggestions • Wash hands with hot soapy water before touching or eating foods. • Cook meat, poultry, fish, and eggs until they are well done. • Wash fresh fruits and vegetables thoroughly. • Drink filtered water. • Wash dishes and cutting boards in hot soapy water. • Use leftovers in refrigerator within 2 days.

30. Strategies for Reducing the Risk of Cryptosporidiosis Data from Centers for Disease Control and Prevention. Cryptosporidiosis: a guide for persons with HIV/AIDS, Atlanta, 1995, CDC.

31. Nutrition-Related Complementary and Alternative Therapies • Herbs/botanicals —Astragalus —Cat’s claw —Echinacea —Garlic —Ginseng —St. John’s wort • Homeostatic macrobiotic diet • Yeast-free diet • Megadoses of vitamins and minerals • Antiviral AL-721 and homemade formulas • Dr. Berger’s Immune Power Diet and maximum immunity diet • Medical marijuana

32. Drug Therapy • Antiretroviral drugs—they block the core enzyme reverse transcriptase that is necessary for viral replication and terminate DNA chain formation • Examples: —AZT (Retrovir) —Videx —Epivir

33. Drug Therapy—cont’d • Protease inhibitors—prevent the formation of mature infectious viruses (they work late in the viral cycle and block the activity of the viral protease) • Examples: —Norvir —Invirase —Crixivan

34. Drug Therapy for Involuntary Weight Loss • Medicine used to promote weight gain after involuntary weight loss as a result of surgery, infections, or severe trauma. • Oxandrin—increases protein synthesis in the skeletal muscle and improves intracellular reutilization of amino acids. It works synergistically with dietary protein.

35. Nutritional Referral Referral information should include the following: • Consent to release medical information • Current diagnosis and medical history • Referring health care provider’s nutrition prescription or desired outcome • Clinical symptoms and feeding route • Weight history and body composition • Recent biochemical data

36. Nutritional Referral—cont’d Referral information should include the following: • Current medications (prescription and nonprescription drugs, vitamins, minerals, and other dietary supplements) • Use of complementary and alternative therapies • Functional status • Lifestyle, psychosocial status, and activity/exercise routine, including substance use pattern