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

2. 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?"

3. 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.

4. 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

5. 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.

6. 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

7. 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

8. 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

9. 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

10. Preventing Wasting Nutrition Education Appetite Stimulants
Anabolic Hormones

11. 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

12. 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

13. High Nutrient Foods Yogurt Cheese Eggs Cottage Cheese Tuna Chicken
Fish
Beans
Lentils
Corn
Leafy Greens
Squash
Yams
Brown Rice
Whole Grains
Tofu, Tempeh, Soy Nuts
All Vegetables
Oatmeal
Wheat Germ
All Fruit
Broccoli
Peanut Butter
Nuts

14. Protein
Eat twice the RDA (Recommended Dietary Allowances) Protein: ( 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

15. 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

16. 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

17. 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)

18. 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.

19. 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.       

20. 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

21. 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”

22. 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).

23. 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).

24. 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.

25. 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.

26. 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.

27. 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.

28. 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

29. 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.

30. 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

31. 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.

32. 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

33. 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...

34. 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.

35. 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.

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

37. 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

38. 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.

39. 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

40. 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.

41. 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

42. 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.

43. 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

44. 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.

45. 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

46. 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

47. 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

48. 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.

49. 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.

50. 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.

51. Nausea & Vomiting
Nausea may be caused by the medicines you are taking or by infections in your body.
Eat small amounts of food real often during the day. Try watching the clock and eating
Don't skip meals
Eat something every 2 to 3 hours. Eat more food at times of the day when you feel good
Don't eat your favorite foods when you are nauseated. This could cause you to be "turned off" by them later.

52. Nausea & Vomiting (cont.)
Eat salty foods, avoid very sweet foods
Eat dry foods such as toast, crackers or dry cereals right from the box. This is especially good to do soon after waking up in the morning
Plain, simple foods are best to eat now. Try these: soups, puddings and custards, ice cream, rice, macaroni, noodles, toast, yogurt, soft-cooked eggs, cream of wheat farina, oatmeal, bananas, canned fruit, mashed potatoes, crackers, cottage cheese and fruit, eggs

53. Nausea & Vomiting (cont.)
Stay away from fried and greasy foods. Use only small amounts of margarine, butter, cream or oil in your food.
Do not drink liquids at the same time that you eat your meals. Drink them minutes before or after eating.
Sometimes just the smell of food can make you feel sick. Open the windows for some fresh air. Avoid making foods that will produce a strong smell in your home, like brewing coffee, frying meats or fish, or cooking spaghetti sauce or chili.
Some medicines cause nausea. If possible, take them at a time of day when nausea will not interfere with meals.
Do not lie down flat for at least 2 hours after eating. If you wish to rest, sit down. If you must lay down after eating, prop your head up at least 4 inches higher than your feet.

54. Diarrhea
Infections, medicines and emotional stress can all cause diarrhea. It can make you feel weak and become dehydrated.
Replace fluids lost to your body in the diarrhea. Drink a lot of liquids--8 or more glasses per day.
Replace the potassium lost to your body in diarrhea. If you do not have enough potassium you can feel very weak. These foods are high in potassium: bananas, potatoes, melons, dried Fruit, juice
Some foods can actually help stop the diarrhea. It would be good for you to eat plain white rice, cream of wheat or farina cereal, toasted white bread, plain macaroni or noodles, boiled eggs, oatmeal, ice cream, jello, applesauce, bananas, canned fruit, mashed potatoes, yogurt, and plain crackers.

55. Diarrhea (cont.)
Don't skip meals, even though you don't feel like eating. Eat small amounts of food every couple of hours.
Stay away from fatty, greasy foods and fried foods.
Stay away from spicy foods.
Avoid foods with a lot of crunchy fiber. They can irritate your intestines. Do not eat raw fruits or raw vegetables or the skins or seeds of any fruit or vegetable. Do not eat corn. Do not eat whole wheat breads. Do not eat nuts.
If you have cramps, stay away from foods that can cause gas. Do not eat dried beans, canned beans, cabbage, broccoli, cauliflower, carbonated drinks, or beer. No chewing gum.

56. Fluids Here are some hints about getting the fluids you need:
Drink at least 2 liters/day (water, broth, bouillon, fruit juice, punch, ginger ale or 7-up)
Carbonated drinks may cause cramps (stirring it in a glass or remove the top from the bottle & let it sit for a couple of hours will reduce bubbles)
Sugar free beverages may cause headaches or diarrhea. If calorie intake compromised you could use the use the sugar in drinks for energy

57. Fluids (cont.)
Avoid beverages that contain caffeine-causes dehydration. Some beverages that contain caffeine are colas and other carbonated drinks, coffee, tea, cocoa, and hot chocolate.
Avoid beverages that contain alcohol-cause dehydration.
Sip your beverages-using a straw might be helpful.
Many people can take liquids best when they are at room temperature.
Suck on ice cubes and Popsicles, or eat jello or sherbet.
You can freeze your favorite beverage in ice cube trays to make your own Popsicles.

58. Mouth Problems
Your doctor can treat most of your HIV-related mouth and eye problems. Sometimes you may also need to see a special dentist or an eye doctor.
Visit a dentist at least twice a year or more often if mouth problems develop.
Your mouth and throat are some of the most sensitive areas of your body. An HIV infection can allow sores to develop there. These sores can make it hurt to chew or swallow and that makes it hard to eat.

59. Mouth Problems (cont.)
Eat soft foods that are smooth in texture. Try mashed potatoes, yogurt, pudding, custards, oatmeal, cream of wheat, ice cream, applesauce, mashed banana, cream soups (cream of mushroom, cream of chicken, cheddar cheese).
Put your food in a blender to make it smooth.
Try baby food.
Use a straw or drink your food from a cup instead of using a spoon.
Try tilting your head forward or back to make swallowing easier.

60. Mouth Problems (cont.)
If you are able to handle some lumps, try scrambled eggs, cottage cheese, macaroni and cheese, baked fish, tuna salad, and canned fruits. Most stews, casseroles and hearty soups would be soft enough to eat, too.
Moisten your food to help it slide down. Cut meats up in small pieces and add gravy to them.
Soak dry foods in milk, coffee or other warm beverage before eating. This works well with toast, crackers, and cookies.
Do not eat spicy foods.

61. Mouth Problems (cont.)
Try cooked vegetables and soft fruits like bananas or canned pears
Avoid acidic fruits ( oranges grapefruit, tomatoes or their juice)
Avoid very hot foods and beverages. If really cold foods feel good, try adding ice to milk and other beverages to make them extra cold. Try eating a lot of ice cream, sherbet or Popsicles to numb some of the pain.
Rinse your mouth whenever you feel you need it. This can moisten your mouth, remove bits of food, and give it a fresher taste.

62. Dry Mouth
Here are some ideas for moistening a dry mouth and a list of foods that are easy to swallow:
Drink mild beverages such as apple juice or punch throughout the day.
Suck on hard candy, especially sour candy. This will help keep your mouth wet.
Talk to your dentist or doctor. They can prescribe artificial saliva drops for you.

63. Dry Mouth (cont.)
Avoid dry foods like crackers, toast or cookies. You may also try soaking them in milk or other liquids before eating.
Add gravy, creamy sauces or juice to your foods to moisten before eating.
Enjoy soups, casseroles and stews, oatmeal or other soft cereals, yogurt, pudding, applesauce and similar moist foods. They are all easy to swallow.

64. Taste Changes
Marinate meat, chicken or fish in sweet fruit juices, sweet wines, beer, Italian dressing, soy sauce or sweet and sour sauce for better taste.
Meat, chicken, fish, tofu or beans may taste better cold.
Add herbs and spices: try basil, oregano or garlic
Add lemon juice, lime juice or vinegar to food to enhance flavor.

65. Taste Changes (cont.)
Sip liquids or try hard candy to get a better taste in your mouth.
Use a mouth wash and brush your teeth at least 2 times daily with a soft toothbrush.
Eat a tart Granny Smith apple wedge or suck on lemon wedges just before meals. This can help to stimulate saliva and help you overcome the metallic taste.

66. Fatigue Fix simple snacks, rather than meals, for yourself.
Let family or friends cook or bring you food. Don't be embarrassed to ask for their help. People like doing things for others.
Try take-out restaurants. Hamburgers, pizza, Mexican food, chicken and Chinese food can all be obtained this way. Some of them are quite low in cost.

67. Fatigue (cont.)
Call a home food delivery service. Many large towns and cities have these. Look in the phone book for "Meals on Wheels." Call your county health department or local AIDS service organization for more information.
If you are going to spend the day in bed, put some favorite foods and drinks in a cooler with ice beside you. Then you can get your rest but not be without food. A food warmer or crock pot could be used in the same way to keep hot foods hot at your bedside.

68. Fatigue (cont.)
Eat canned foods. Try creamed soups, spaghetti, chili, chow- mein and other things. If you eat a piece of fruit for dessert and drink a glass of milk or juice, you've got a balanced meal.
Eat frozen foods. Frozen dinners, pizza, egg rolls, macaroni and cheese, fried chicken and fish. Just pop them in the oven, and set a timer. Drink a glass of milk or juice, add a piece of toast or fruit.
Cook extra food and freeze it in little plastic containers. You'll be grateful to have these to heat up on days that you are tired.
Make as few dirty dishes as possible. Use paper cups and dishes, cook in the foil pans that frozen food comes in.

69. Food Safety Guidelines
Wash all fresh fruits and vegetables thoroughly. Use a vegetable brush designed for this purpose.
Throw away any fruit or vegetable which has a rotten or moldy spot on it.
Don't let hot foods cool down at room temperature. Put them in the refrigerator right away. If it is a large amount of food, put it in 2 or 3 containers so the refrigerator can cool it all quickly.
Keep your refrigerator cold. You might wish to get a refrigerator thermometer. Keep it set no higher than 40 degrees. Your freezer should be at 0 degrees.
Don't taste anything that you think might be spoiled. If in doubt, throw it out.

70. Sanitation
Use hot, sudsy water to wash your dishes. Let it out of the sink when it gets dirty and replace it with new. Any food germs left on your plate can make you sick the next time you eat from it.
Keep everything clean. Clean your counters often and clean them well. Wash your hands with soap and water a lot during cooking.
If you have old dishes, cups or plastic containers with a lot of scratches in them, throw t hem out. Germs love to hide in scratches and they are very difficult to clean out of there.
Wear rubber gloves when handling raw meat. This will prevent germs from entering any open cuts or sores on your hands.

71. Handling Animal Products
Cook meat thoroughly. You might want to buy a meat thermometer to help you know for sure that it is done. Put the thermometer in the thickest part of the meat and not touching a bone. Cook the meat till it reaches 165 to 212 degrees on your thermometer.
Thaw frozen meats and other frozen foods In the refrigerator or in a microwave oven set to defrost. Never thaw foods at room temperature. Germs that grow at room temperature can make you very sick.
Use different cutting boards for raw foods and cooked foods.
Throw away moldy cheese. It is not good enough to just cut off the moldy part.

72. Safe Food Shopping Diary Products should be pasteurized
Avoid “Sell by" or "best used by" date that has passed.
Put packaged meat, poultry or fish into plastic bag before placing it in the shopping cart
After shopping, get chilled and frozen foods into refrigerator or freezer as soon as possible.
Storing food for 2 hours in warm temperatures allow bacteria to grow.
Sale of food products with damaged packaging, the unsafe displaying of products (such as cooked shrimp on the same bed of ice as raw seafood), workers with poor personal hygiene, and unsanitary store conditions can add to the risk of food-borne illness

73. Rules for Eating Eggs
Pasteurized eggs should be used in place of shell eggs when making homemade ice cream, eggnog and mayonnaise.
Don't eat raw eggs. If you wish to add a an egg to a milkshake or make egg nog, use a frozen product called "Eggbeaters" instead.
Don't use cracked eggs. Look for cracks in the shells before you buy them.

74. Rules for Eating Eggs (cont.)
COOKING INSTRUCTIONS:
Scrambled-1 minute at medium stove top setting (250 deg F for electric frying pans).
Sunnyside-7 minutes at medium setting (250 deg F) or cook covered 4 minutes at 250 deg F.
Fried, over easy-3 minutes at medium setting (250 deg F) on one side, then turn and fry for another minute on the other side.
Poached-5 minutes in boiling water.
Boiled-7 minutes in boiling water.

75. Eating Out
Always order food well-done; if it served medium to rare, send it back.
Order fried eggs cooked on both sides instead of sunny side up, and avoid scrambled eggs that look runny.
Caesar salad should also be avoided since it contains raw eggs.
Raw seafood (sushi) poses a serious risk of food poisoning for persons with AIDS.
Raw shellfish, like raw meat and poultry, should be assumed to harbor harmful bacteria.
Oysters on the half shell, raw clams, sushi and sashimi should not be eaten. Lightly steamed seafood, such as mussels and snails, should be avoided.

76. Traveling Abroad
Boil all water before drinking. Drink only beverages made with boiled water or canned or carbonated bottled drinks. Ice, too, should be made only from boiled water.
Avoid uncooked vegetables and salads. All fruit should be peeled. Eat cooked foods while they are still hot.
A good rule of thumb is "Boil it, cook it, peel it, or forget it."

77. Exercise
Several studies have shown aerobic exercise improves quality of life for people with HIV.
Studies have also suggested exercise has beneficial effects on the immune system such as increasing CD4+ cells.
Exercising to the point of exhaustion, however, has been shown to be immune suppressive.
The biggest benefit of exercise for HIV+ people may be the building and retention of muscle mass.
Exercise, including working out with weights, and swimming, has been shown to improve muscle function and to build lean muscle mass in HIV+ people.
Any type of exercise also has the benefit of releasing stress, and may help increase your appetite.

78. Ritonavir (Norvir)
To lessen stomach upset and improve absorption , Take on a full stomach, preferably a meal high in fat (e.g. lean red meat, peanut butter, avocado, cheese, bread with butter, whole or 2 % milk products).
Each capsule should be taken separately with a good drink of milk or spoonful of yogurt.
Take every 12 hours.
What not to do:
Don't miss a dose or take less than prescribed. If you miss a dose, take the next dose at the regular time scheduled. Do not double dose.
Limit/avoid alcohol. It can severely damage your liver.

79. Disguising the Taste of the Liquid
Disguise taste by mixing dose with chocolate milk, frozen juice concentrate, jam, Hershey chocolate syrup or take with 1 tsp. of peanut butter.
Taste tests show that very sweet foods can help with the after taste such as Nutella hazelnut spread on graham crackers or an oats and honey granola bar.
Also try drinking liquid solution with a straw placed at the back of the throat, bypassing the taste buds.
You can also numb the taste buds by sucking on a frozen Popsicle before and after dose.

80. Storing Norvir
Store capsules in the refrigerator between degrees F.
You can keep your daily dose at room temperature for up to 12 hours.
Keep away from light.
Storing Liquid Solution:
Refrigeration is not required for solution kept below 77 degrees F and used within 30 days.

81. Indinavir (Crixivan)
Crixivan should be taken on an empty stomach or a low-protein, low-fat meal -300 calories, 5 grams protein and 2 grams fat.
Take every 8 hours exactly- one hour before a meal or two hours after a meal. (For example: finish eating lunch by 12 noon, take Crixivan at 2 PM, then have a light snack at 3 PM).
Drink at least 1 cup (8 ounces) of water or juice (not grapefruit) with each dose.
Drink at least a total of 10 cups total of water and/or juice every day to avoid kidney stones.
What not to do:
Don't miss a dose or take less than prescribed. Do not double dose.
Don't take Crixivan with a big meal which contains fat and protein
Do not take Crixivan with grapefruit juice or a grapefruit. Other juices have no affect.

82. Saquinavir (Fortovase )
Take every 12 hours when taken along with Ritonavir.
Take within 2 hours of a high fat meal or snack (Taking it with high fat foods lets your body absorb 5 to 10 times more. )
Take your dose with at least 20 grams of fat (read labels).
What not to do:
Don't take Saquinavir on an empty stomach. Don't take it with a meal low in fat and calories. Don't miss a dose or take less than prescribed. If you miss a dose, take next dose at the regular time scheduled. Do not double dose.

83. Nelfinavir Mesylate (Viracept )
Take 3 times a day. Space out with the meals you eat.
Be sure to wait at least 4 hours between doses and no longer than 12 hours between doses. Be sure that your evening dose and morning dose are not more than 12 hours apart.
Take Nelfinavir with food which contains at least 500 calories. No specific foods help increase or decrease absorption.
What not to do:
It's not recommended to take Nelfinavir on an empty stomach since you may get more severe side effects.

84. Side Effects- Protease Inhibitors
Nephrolithiasis (kidney stones, indicated by pain in the sides, blood in urine) occurred in % of people in clinical studies.
Drinking those 6 extra large glasses of water throughout the day can help prevent nephrolithiasis.
Less common side effects include nausea, abdominal pain, headache, weakness/fatigue, diarrhea, taste changes and back pain.

85. Side Effects- Protease Inhibitors
Nausea, diarrhea, vomiting, stomach pain, taste change, fatigue, mild to severe skin sensitivity and numbness around the mouth.
Of all the protease inhibitors, Norvir is most likely to cause liver function problems and raise blood lipid (fat) levels.
Taking protease inhibitors such as Norvir also has been associated with fat deposits on the back (buffalo hump) and around the waist as well as breast enlargement.
Liver function tests should be monitored regularly.

86. Possible Causes Of Insulin Resistance
Testosterone deficiency
Some medications ( Protease Inhibitors)
Family history/genetics
Obesity/overweight
Depleted glutathione which can affect insulin sensitivity.

87. Dietary Modification for Insulin Resistance
Consume moderate portion sizes.
Eat balanced meals consisting of a complex starch (brown rice, whole wheat bread), lean protein, fat and vegetable or fruit.
Consume high fiber foods in the form of whole grains (whole wheat bread, brown rice, bran cereals etc.) and vegetables to reduce the rate of glucose absorption from the gut into the blood stream.
Increase consumption of rich-colored vegetables and fruits for their protective vitamins, antioxidants, and phytochemicals.

88. Diet & Blood Glucose
Reduce consumption of simple sugars (sodas, sweets, etc.) and refined starches (white bread, pasta, and others made from white flour) to prevent blood glucose levels from rising too rapidly.
Reduce saturated fat intake.
Consume mostly unsaturated fats like olive or canola oils and omega-3 fatty acids from cold water fish (tuna, sardines, salmon, and mackerel, for example).
Include lean protein from chicken, lean beef, fish, nuts, low-fat cottage cheese, beans, and whey protein shakes to help build and maintain lean body mass and manufacture antibodies to fight disease.
Limit alcohol consumption. Alcohol may interfere with the liver's ability to break down glucose.

89. Complementary Approaches For Improving Insulin Sensitivity
Regular resistance (weight-bearing) exercise.
Testosterone replacement, when needed, will also promote muscle building.
A high-potency multiple vitamin and mineral formula.
Extra amounts of glutathione-boosting nutrients: alpha-lipoic acid (600-1,200 mg daily), N-acetyl-cysteine (NAC) (1,500-3,000 mg daily), vitamin C (2,000-6,000 mg daily), vitamin E (1,200 IU daily), and glutamine (5-10 grams daily, increased to grams in those with severe muscle loss); all taken in three divided doses.

90. Complementary Approaches For Improving Insulin Sensitivity (cont.)
Chromium mcg, taken three times daily.
L-carnitine in doses of mg per day.
Magnesium (500-1,000 mg daily) for carbohydrate metabolism.
Fish oil in soft gel form to increase insulin sensitivity and reduce triglyceride levels.
Milk thistle standardized for 80% silymarin has powerful effects as an antioxidant, a protector of the liver, and an agent that may help improve insulin sensitivity

91. St John’s Wort
May significantly decrease blood concentrations of all of the currently marketed HIV protease inhibitors (PIs) and possibly other drugs (to varying degrees) that are similarly metabolized, including the non nucleoside reverse transcriptase inhibitors (NNRTIs).
Concomitant use of St John’s Wort with PIs or NNRTIs is not recommended because this may result in suboptimal antiretroviral drug concentrations, leading to loss of virologic response and development of resistance or class cross-resistance.

92. Case Study Questions Weight gain from Protease Inhibitors?
Using herbal “Fat Burners” to lose weight?
20% weight loss in 2 months?
Drinking soda to meet fluid needs?

93. Q #1: Patient on crixivan for about 4 months - gained about 35 lbs
Q #1: Patient on crixivan for about 4 months - gained about 35 lbs. When will I see a decrease in my weight?
Now that protease-inhibitors are not the only cause of lipodystrophy, other drugs or just treating HIV may be the cause of body changes.
Decrease your calories, exercise aerobically, and have your doctor check your testosterone.
Include resistant type exercise to increase muscle mass which will enhance metabolism
By including exercise- this allows you to increase caloric expenditure without decreasing the intake of high nutrient foods

94. Q #2: Xenadrine : Cholesterol & Weight loss
CONTAINS THE FOLLOWING:
Pantothenic acid - 40mg, bitter orange -85mg
Ma huang mg, Guarana extract - 910mg
White willow bark extract - 105mg, Ginger root - 50mg
Tyrosine, actyl l-carnitine, , magnesium phosphate, DMAE, calcium
Most of these multi-ingredient products have multiple claims attached but little or no research to back up the claims.
All fat burners contain ephedrine derivative which can accelerate your heart rate, depress appetite, and contain diuretic herbs to increase urine output
They also contain large amounts of caffeine which can cause diarrhea and dehydration

95. Q #3: Patient lost ~ 20% within 2 months
Lost strength in his body
Roommate prepared high calorie, protein shake to give him that extra nutrition and protein boost
Ingredients were: soy protein, nutritional yeast, wheat germ, soy lecithin, bee pollen, yogurt and fruits.
It is high in calories, vitamins, and replenishes his friendly bacteria.
Estimated that the shake is about 75% protein.
Consumes this only once a day along with fresh fruits and veggies.
He's only been taking the protein shake for about 2 weeks but I've seen dramatic results with his weight gain.
1 cup plain yogurt, 2 scoops soy protein, 2 tbs bee pollen, 2tbs soy lecithin, 1tbs nutritional yeast, 1tbs wheat germ, 1 banana, handful of any berries.

96. Nutritional Concerns
In my view, the specific ingredients are not as important as the general effect: more calories, more protein, and more micronutrients.
Patient needs to be encouraged to eat real food
Important not to rely on one source, like a shake, too much. He may develop taste fatigue of it, or you may go on vacation & patient needs to have more variety
Plus, no single shake can provide everything that a person needs. So he should keep trying to find ways to maintain his food intake.
Also suggest weigh your roommate on a regular basis (same time of day, same scale, same clothing state), if this is feasible, to document how well the plan is working

97. Q #4: Soda Vs. Water?
Lots of calories (weight gain), worse triglycerides, tooth decay, less quenching of thirst due to the concentrated sugar, increase in BG if insulin resistant, added caffeine and dehydration.
Diet soda is a different story. There is little difference from water, physiologically. If it has caffeine in it, this is a potential issue. Some artificial sweeteners can cause headaches or loose stools.
Try flavored seltzer, lemon/lime/orange slices in water, slivers of ginger in water, herbal teas ( iced or hot ).
Try Splenda (sucrolose)- this is going to be on the market 2001 & is found in RC cola and some other products

98. Case Study - Conference
At a recent HIV/AIDS conference that I attended, a doctor described the miraculous recovery of one of his patients who had come back from severe wasting and TB and was healthy enough to begin fighting her HIV successfully. He talked about her medication schedule in detail, but failed to mention nutrition.
During the question-and-answer period that followed his presentation, I asked him about this patient's nutrition support. He apologized for his oversight and repeated to the audience an expression he had been told by one of his patients at his clinic in Haiti:
"Taking medicine without eating properly is like washing your hands and drying them in the dirt."