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

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

2 NY/VI AETC 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 NY/VI AETC 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 NY/VI AETC 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 NY/VI AETC 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 NY/VI AETC 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 NY/VI AETC 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 NY/VI AETC 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 NY/VI AETC 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 NY/VI AETC Preventing Wasting Nutrition Education Appetite Stimulants Anabolic Hormones

11 NY/VI AETC 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 NY/VI AETC Calories Estimation of Calorie Needs: 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 NY/VI AETC 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 NY/VI AETC 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 NY/VI AETC 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 NY/VI AETC 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 NY/VI AETC 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 NY/VI AETC 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 NY/VI AETC 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 NY/VI AETC 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 NY/VI AETC 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 NY/VI AETC 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 NY/VI AETC 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 NY/VI AETC 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 NY/VI AETC 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 NY/VI AETC 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 NY/VI AETC 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 NY/VI AETC 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 NY/VI AETC 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 NY/VI AETC 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 NY/VI AETC 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 NY/VI AETC 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 NY/VI AETC 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 NY/VI AETC 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 NY/VI AETC 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 NY/VI AETC Commonly Used Liquid Supplements Instant Breakfast Slender ® Ensure®;Sustacal®;Enrich®; Magnacal®;Ensure Plus®;Repleat®; Nutrament®;Alba®;Meritene®;Citrotein® Nutri1000®;Resource®;

37 NY/VI AETC 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 NY/VI AETC 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 NY/VI AETC 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 NY/VI AETC 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 NY/VI AETC 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 NY/VI AETC 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 NY/VI AETC 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 B 12 Higher doses of other vitamins like C, E, and the mineral selenium

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

87 NY/VI AETC 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 NY/VI AETC 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 NY/VI AETC 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 NY/VI AETC 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 NY/VI AETC St Johns 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 Johns 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 NY/VI AETC Case Study Questions 1.Weight gain from Protease Inhibitors? 2.Using herbal Fat Burners to lose weight? 3.20% weight loss in 2 months? 4.Drinking soda to meet fluid needs?

93 NY/VI AETC 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 NY/VI AETC 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 NY/VI AETC 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 NY/VI AETC 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 NY/VI AETC 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 NY/VI AETC 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."


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